LASH LIFT CONSENT FORM

LASH LIFT CONSENT FORM
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email*
Date of Birth*

MonthDayYear
mm-dd-yyyy
How did you hear about us?*

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Social media handles
Instagram, Facebook
Please list any known allergies:*
Including adhesives, glues, tapes, bandaids, etc. or N/A
Emergency Contact*

Full Name Cell Name
Our Policies

Please take a moment to complete our consent form. By submitting the form below you agree to knowingly and willingly consenting to our policies and procedures.
24- hour notice is required for any canceled or rescheduled appointment or up to 100% of service price will be charged. Failure to show without notice will require in full payment of service booked. We do not offer monetary refunds on services rendered. We do have a 7-day policy in place on services in which a client can come back and have corrections made provided they notify us of any issues within the first 24-48hours of the service.Client must contact provider within 24-48hours after service rendered of any issues. Fees may apply. By choosing yes, I’m acknowledging I have read, understand, and agree with the terms of these policies.*

Yes
I agree to have a lash lift applied to my natural eyelashes.*

Yes
I understand there are risks associated with having a lash lift. 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 understand that even though we use the proper technique, the instruments, tapes, cleaners, eye gel pads, adhesives, and removers used may irritate my eyes.*

Yes
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.*

Yes
I understand that if I come to my appointment with waterproof mascara, my technician may not be able to remove it completely and it may affect the outcome of my lash lift.______I understand and consent to having my eyes closed and covered for the duration of the 45-75 minute procedure.*

Yes
I understand there are no guarantees for curl tightness and RESULTS WILL VARY.*

Yes
I understand that there is no guarantees for the length of time the lashes will be curled and results vary.*

Yes
I understand that there are many factors that may affect the life of the lash lift such as; water and moisture contact, weather conditions, and activities involving exposure to high temperatures.*

Yes
Because RESULTS VARY and are NOT GUARANTEED, refunds will not be issued if results are not desired. There will be a 50% charge for re-do’s within 7 days of initial service.*

Yes
I am informing my technician of the following conditions by marking with a check:*

Current use of contact lenses which I agree to remove during applicationCurrent use of anything such as oil-containing sunscreen or moisturizers around the eyesCurrent use of eye drops of any kind, prescription or over-the-counterCurrent allergies or sensitivities to instruments, fumes, tapes, cleaners, eye gel pads, adhesives, and removers that could cause my eyes to water and blink in excessHistory of recurrent eye or tear duct infectionsHistory of dry eyes or Sjorgen’s SyndromeRecent history of ChemotherapyOther medical conditions which would prohibit or compromise the process and retention of this lash liftNone of the above
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. This agreement will remain in effect for this procedure and all future procedures conducted by my technician. I have read and fully understand all information in this agreement. I am over 18 years of age and consent to the agreement and to treatment.
May we use your photos/videos per the above paragraph?*

YesNo
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LASH LIFT CONSENT FORM

Our Policies