Eyelash Lift and Tint Consent Form
Name
First Name
Last Name
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about us?
Website
Social Media
Google Search
Friend
Other
Have you ever had a lash lift before?
Yes
No
Health History | Please check any of the following that applies to you
Allergy to adhesives band aid or medical tape
Allergy to surgical glue or nail glue
Seasonal allergies
Allergy to glycerin
Eye illness or injury
Blepharitis (inflamed eyelids)
Eye lift
Drugs that can cause temporary hair loss
Major surgery within last 120 days
Other
List any details I should know if you checked anything above:
Have you ever had an allergic reaction to hair color/tint?
Yes
No
Do you wear contact lenses
Yes
No
PRE- CARE LASH LIFT
Do not wear mascara or eye makeup the day of your lash lift appointment.
Please do not use oily makeup remover the day before or day of your appointment
Please remove contact lenses before your lash lift appointment. Bring glasses with you.
Avoid that second cup of caffeine or energy drink prior to your appointment. It is important that your eyes remain calm during your appointment
POST- CARE LASH LIFT
Keep the lashes dry: For the first 24 hours, avoid contact with water, including washing your face, swimming, or using steam rooms.
Avoid rubbing or touching them excessively
Sleep on your back
Avoid applying eye makeup
Avoid oil-based products
Please agree to the terms and conditions
I understand that there are risks associated with having eyelash lift and tint
I understand and agree to the after-care instructions and for any unexpected circumstance that have happened due to not following these instructions are in my own risk.
I understand that in rare occasions there are risks associated with having eyelash lift and tint, I further understand that in rare circumstances eye or skin irritation and discomfort may occur.
I understand that an eyelash lift will lift my natural eyelashes. Depending on my natural eyelash length and strength, results may vary.
I agree that if I experience any of these conditions with my eyelashes or eyes, that I will contact my esthetician; if I choose to consult a physician, it will be at my own expense
I hereby grant my esthetician the full right to take, publish and reproduce photographs/videos of me, my face, my eyes and/or eyelashes, both before and after this procedure, for any advertising, insurance, and other purposes whatsoever. I further expressly assign any copyright in these photographs to my esthetician and their business. Please use these images with the following:
I Grant Consent
I Do Not Grant Consent
Date
-
Month
-
Day
Year
Date
Client Signature
Submit
Submit
Should be Empty: