Lash Lift & Tint Consent

Name*

First NameLast Name

Birthday*

You must be 18 or older otherwise accompanied by a parent/guardian

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

My desired outcome for today’s treatment would be..*

I consent to having my eyes closed and covered for the duration of the 45-60 minute procedure.*

YesNo

I am informing my technician of any of the following contraindicated conditions.*

Do you have any sensitivities which haven’t been specified? Please explain.*

Do you have any other allergies, or medical concerns we should be aware of prior to conducting this service?*

Do you wear contacts? if you are, please remove.*

YesNo

Are you pregnant or breastfeeding?*

YesNo

How did you hear about us? Please list their name(s) in the “Referrer” section for both of you to qualify for future discounts!*

I, understand and agree to the following statements:*

I agree to have an eyelash lift (perm) and/or eyelash tint applied to my natural eyelashes and/or retouched. By signing this agreement, I consent to the procedure of an eyelash perm or eyelash tint by my technician.I understand there are risks associated with having an eyelash perm and/or eyelash tint. I further understand that as part of the procedure, eye irritation, eye pain, eye itching, discomfort, and in rare cases eye infection or blurriness could occur. I agree that if I experience any of these medical conditions with my lashes that I will contact my technician and consult a physician at my own expense.I understand that even though my technician perms the lashes using the proper technique, the instruments, tapes, cleaners, eye gel pads, adhesives, and removers used may irritate my eyes or require a physician’s follow-up care.I understand and agree to the care instructions provided by my technician for the use and care of my permed and/or tinted eyelashes. I realize and accept the consequences of failure to adhere to these instructions may cause the eyelashes to not stay permed as long as told.I agree as post-lash lift that no water can come in contact with the eye area for 24 hours after the application and I avoid using oil containing sunscreens, moisturizers and cleansers of on lashes.I am over 18 years of age and consent to the agreement and to treatment or have a parent with me that consents to this service. This agreement will remain in effect for this procedure and all future procedures conducted by my technician. I read English and understand that this consent agreement is legal and binding. I have read and fully understand all information in this agreement. I release my technician from all liability associated with this procedure, which is performed with the utmost attention to safety and proper application using tools and products that the technician has been professionally trained to use. There are no guarantees for length of time the lashes will stay permed. I understand the aftercare instructions and will do my part to maintain my eyelashes. I understand that there are many factors that may affect the life of the eyelash lift such as water and moisture contact, weather conditions, and activities involving exposure to high temperatures. By signing below, I verify that I have read and understand the above statements and agree to them.

Date*

Date

Signature*

Lash Lift & Tint Consent Form