Lash Lift Consult Form

1
Name* This field is required.
First Name
Last Name
2
Phone Number* This field is required.
Please enter a valid phone number.
3
Date of Birth* This field is required.
mm-dd-yyyy
4
Appointment Date* This field is required.
Date
Month
Day
Year
5
How did you hear about us?* This field is required.
6
Have you had a lash lift treatment before?* This field is required.
Yes
No
7
I consent to having my eyes closed and covered for the duration of the 45-60 minute procedure.* This field is required.
Yes
No
8
I am informing my technician of the following conditions by marking with a check:Check all that apply
Current use of contact lenses which I agree to remove before treatment
Current use of anything such as oil-containing sunscreen or moisturizers around the eyes
Current use of eyedrops of any kind, prescription or over-the-counter
Current allergies or sensitivities to instruments, fumes, tapes, cleansers, eye gel pads, adhesives and removers that could cause my eyes to water and blink in excess
History of recurrent eye or tear duct infections
History of dry eyes
Recent history of chemotherapy
Other medical conditions which would prohibit and compromise the process and retention of these treatments
9
Agreement:

∙ I agree to have an eyelash lift (perm) and/or eyelash tint applied to my natural eyelashes, and/or retouched. By submitting this agreement, I consent to the procedure of an eyelash lift and/ or eyelash tint by Modern Glow Aesthetics.
∙ I understand there are risks associated with having an eyelash lift and/or eyelash tint. I further understand that as part of the procedure, eye/skin irritation, eye pain, eye itching, discomfort, and in very rare cases eye infection or blurriness could occur. I agree that if I experience any of these medical conditions with my lashes/skin that I will contact Modern Glow Aesthetics and consult a physician at my own expense.
∙ I understand that even though my technician lifts the lashes using the proper technique, the instruments, tapes, cleaners, eye gel pads, adhesives, and removers used may irritate my eyes/skin or may 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 lifted 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.
10
I agree to the following Post- Lash Lift/Eyelash Tint:

First 24 hours:
∙ No water can come in contact with the eye/brow area for 24 hours after the application
∙ Avoid steam, saunas, heat, water or heavy workouts causing sweat.
∙ Do not have any other facial treatment
∙ Avoid direct sunlight

After 24 hours:
∙ Avoid using oil containing sunscreens, moisturizers and cleansers on the lashes.
∙ Wait 48 hours to apply mascara. Avoid using water-proof mascara.
∙ Avoid sleeping/rubbing freshly lifted lashes
∙ Reschedule your next lash lift in 6-8 weeks
TIP: Try to sleep on your back for the first 48 hours. If you sleep on your side or on your face it could affect the shape of your lashes.
11
* This field is required.Acknowledgement and Waiver 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 Modern Glow Aesthetics. 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 Modern Glow Aesthetics from all liability associated with these treatments, 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 submitting below, I verify that I have read and understand the above statements and agree to them.
Should be Empty: