Lash Lift Intake & Consent Form
Please fill this out in it's entirety before your appt
For any questions email lushskinaesthetics@gmail.com
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Have you had a lash lift or lash tint in the past?
Please Select
Yes
No
Have you ever had a reaction to hair dye or lash/brow tint?
Please Select
Yes
No
Do you wear contact lenses?
Please Select
Yes
No
Are you currently using eye drops of any kind, prescription or over-the-counter?
Please Select
Yes
No
Do you have a history of recurrent eye or tear duct infections?
Please Select
Yes
No
Do you consent to photos/videos taken for purposes of education or content? You can always opt out later
Please Select
Yes
No
List any allergies you have:
List any illnesses, medical conditions, or medical treatments you have recently received that would prohibit or compromise the process and retention of this eyelash lift:
Although every precaution will be taken to ensure your safety and well-being before, during, and after your eyelash lift, please be aware of the following information and possible risks. By agreeing to the statements below you are giving your consent to get a lash lift/tint treatment.
I accept the following statements;
I understand that there are risks associated with having an eyelash lift.
I understand that as part of the eyelash lift procedure, eye irritation, eye pain, eye itching, discomfort, and inrare cases, eye infection or blurriness could occur.
I agree that if I experience any of these conditions with my eyelashes or eyes, that I will contact mytechnician; if I choose to consult a physician, it will be at my own expense
I understand that the instruments, tapes, cleaners, eye gel pads, adhesives, and/or removers may irritate myeyes or require a physician’s follow-up care, even though my technician utilized correct techniques and followedproper safety protocols.
I understand that an eyelash lift will lift my natural eyelashes. Depending on my natural eyelash length and strength, results may vary.
I understand and agree to the care instructions provided by my technician for the use and care of myeyelashes after the eyelash lift. I realize and accept that the consequences of failure to adhere to theseinstructions may cause the eyelashes to not stay as lifted as long as originally told.
I understand and consent to having my eyes closed and covered for the entire duration of the procedure.
I understand all services rendered are final sale with no refunds.
I agree to the following eyelash lift care and maintenance instructions:
No water can come in contact with the eye area for 24 hours after the applications.This agreement will remain in effect for this procedure and all future procedures conducted by my technician.I have read the above information. If I have any concerns, I will address these with my esthetician/technician. I give permission to my esthetician/technician to perform the eyelash lifting procedure we have discussed and will hold her harmless from any liability that may result from this treatment. I have accurately answered the questions above, including all known allergies, prescription drugs, or products I am currently ingesting or using topically. I understand my esthetician/technician will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult the esthetician/technician immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks.I do not hold the esthetician/technician, Adriana Ramos, responsible for any of my conditions that were present, but not disclosed at the time of this procedure that may be affected by the treatment performed today. By signing below I agree to the above.
Signature
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