PINKED - Questionnaire & Release Form

Full Name*

First NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Birth*

MonthDayYear
Date
Medical History and Allergies*

History of eye infections or eye conditionsSkin conditions or sensitivitiesHistory of allergic reactions to cosmetics or adhesivesCurrent medications that may affect proceduresPregnancy or breastfeeding statusOther health concerns
Please specify any allergies or sensitivities you have (e.g., latex, adhesives, cosmetics):
Previous Experience with Lash Extensions or Permanent Makeup*

Yes, I have previous experienceNo, I am a first-timer
If yes, please describe your previous experience and any issues encountered:
Consent and Acknowledgments*

I consent to the procedures and understand the risks involved.I agree to follow the aftercare instructions provided.I understand that individual results may vary and that touch-up sessions may be necessary.I consent to the use of my photos for promotional purposes (if applicable).
Client Expectations and Special Requests (e.g., specific styles, concerns):

Aftercare Instructions Acknowledgment*

I have read and understood the aftercare instructions.I agree to schedule follow-up appointments if needed.
Liability Release

I, the undersigned client, understand and acknowledge that all treatments provided are for the purpose of skin health, relaxation, and cosmetic improvement.

I understand that:
- Esthetic treatments (including but not limited to facials, waxing, peels, microdermabrasion, and other skin care services) involve certain risks, including but not limited to redness, irritation, sensitivity, allergic reactions, or other side effects.
- It is my responsibility to inform my esthetician of any medical conditions, allergies, medications, or skin sensitivities that may affect my treatment or results.
- Results may vary, and no guarantees of specific outcomes have been made.
By signing below, I acknowledge that I have disclosed all relevant health information, and I consent to receive esthetic treatments at my own risk. I release and hold harmless Macy Boselli (PINKED - Lines and Lashes LLC), its employees, and contractors from any and all liability for injury, adverse reactions, or complications resulting from services rendered.
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