Lash Lift & Tint New Client Consultation and Consent Form
Please fill out this form to provide your information and give your consent for the upcoming and future lash lift and tint appointments.
Full Name
*
First Name
Middle Name
Last Name
Birthdate
*
-
Month
-
Day
Year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name & Mobile
*
Have you received lash lift & tint before?
*
Yes
Now
If yes, please provide last “lash lift” service date.
If yes, please provide last “lash tint” service date.
Please pick if any apply
*
Chemotherapy / Post Chemotherapy
Allergies to Latex / Band Aids / Under Eye Pads
On Contraceptive Pill / Hrt
Cataracts
Bells Palsy
Claustrophobia
Hey Fever / Allergies
Eye Disease
Inflammation Of The Skin
Pregnant/ Lactating
Blepharitis
Recent Operations
Allergies To Glue / Adhesive
Glaucoma
Skin Disorders
Eye Inflammation
Recent Eye Surgery
Alopecia
Watery Eyes
Eye Infections
Dry Eye Syndrome
Other
If other please provide other allergies/detail of history or other factors.
Have you ever used hair color/lash tint or “at home lift kit”?
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Yes
No
Have you ever had an allergic reaction to lash tint?
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Yes
No
Have you ever had an allergic reaction to lash lift?
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Yes
No
Do you wear glasses or contacts?
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Contacts
Glasses
None
What are your lash goals?
*
Longer
Fuller
Intense Lift
Maximum Curl
Straighten
Soft Curl
Deeper Color
Natural Lift
Dark Color
Other
If other, please provide in detail your lash goals.
Would you prefer your appointment to be silent?
*
Yes, I would like my appointment silent.
No, I would not like my appointment silent.
Undecided
Provide any other important information you would like for me to know to provide the best experience and service possible for you.
Lash Lift & Tint Aftercare: I understand that I must be gentle with my lashes. Avoid rubbing, pulling, or applying pressure. My lashes should remain dry for the first 24-48 hours after treatment. Use of steam, sauna, or swimming may be resumed after 24-48 hours but may reduce the longevity or strength of the lift. I agree to avoid sleeping on my face or the side of my face possible effecting my lift. I agree to avoid harsh products, oil-based cleansers or makeup, and waterproof mascara. I agree to brush them daily morning and night to help maintain the lift and shape of my lashes.
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I understand
Other
We highly value your privacy and the trust you place in us. Please be assured that all personal and health information provided in this form will be kept confidential. The information you share is used exclusively for the purpose of providing personalized lash lift services and will not be disclosed to any third parties without your explicit consent, except as required by law. We implement a variety of security measures to maintain the safety of your personal information. Access to your data is strictly limited to authorized personnel who are trained in handling client information securely and confidentially. By signing this form, you acknowledge that you understand our commitment to protecting your privacy and agree to the collection and use of your information as described above.
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Yes
Other
I have read, understand and agree to the above Confidentiality Clause.
*
Yes
Other
I hereby grant the above mentioned salon the right to use and publish photographs taken of me during my appointment for marketing, promotional and other business purposes. I understand these images may be used in print, digital media, or online platforms. I waive any right to inspect or approve the finished product and acknowledge that I am not entitled to any compensation for the use of these images. I release the above mentioned salon from all claims and liability relating to said photographs.
*
Yes
Other
I have read, understand and agree to the above Image Release Clause. If you do not agree to this, please refrain from signing this section.
*
Yes
Other
I acknowledge that I am aware of the risks involved with the treatment being performed, I have been informed of the procedure and the aftercare and I consent to receive this treatment. I agree to not hold the salon or technician liable for any unforeseen adverse reactions provided the salon or technician follows the proper procedure for this service.
*
Yes
Other
I understand and acknowledge that receiving a patch test without showing any signs of reaction or sensitivity does not guarantee that an allergic reaction is not possible.
*
Yes
Other
I have received a patch test or I haven’t received a patch test, and I am happy to continue with the treatment.
*
Yes
Yes, I received a patch test
Other
I understand and acknowledge that receiving a patch test without showing any signs of reaction or sensitivity does not guarantee that an allergic reaction is not possible.
*
Yes
Other
I understand that as part of the eyelash lift procedure, eye irritation, eye itching, discomfort, and in rare cases, eye infection or blurred vision could occur.
*
Yes
Other
I agree that if I experience any of these conditions with my eyelashes or eyes, that I will contact my technician; if I choose to consult a physician, it will be at my own expense.
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Yes
Other
I understand that there may be some residual dark staining left on the skin following the tinting process of my lashes. This will fade and go away within a short time.
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Yes
Other
I understand that, while every attempt will be made to provide me with my chosen color, everyone’s hair absorbs color differently and my final results may not be the color I initially wanted.
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Yes
Other
I understand that over the course of several weeks, the tint will gradually lighten and fade. Re-tinting will be required to keep the new color fresh.
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Yes
Other
I understand that an eyelash lift will lift my natural eyelashes and is an enhancement of my natural lashes. Depending on my natural eyelash length and strength, results may vary.
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Yes
Other
Reservation & Cancellation Policy for all current and future appointments: In the event of cancellations received less than 24 hours prior to appointment a cancellation fee equal to the reserved service booking will incur. No Shows will be charged 50% of the service booked. As well as non refundable deposit. If running 15 minutes late or more, appointment may be cancelled.
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I understand
Other
By signing below, I acknowledge and agree to follow all lash lift and tint care and maintenance instructions to ensure the best results and longevity of my treatment. This agreement remains valid for this and all future lash lift or tint services performed by my technician. I have read and understand all information provided, and I agree to communicate any questions or concerns directly with my technician. I give Allyson Johnson permission to perform the lash lift and tint procedure we have discussed and release her and any associates from liability for any reactions or complications that may occur, provided all proper procedures have been followed.I confirm that I have answered all questions truthfully, including disclosing any allergies, medications, or products I currently use. I understand that every precaution will be taken to minimize risk, but no results can be guaranteed.I acknowledge that this form serves as full disclosure and replaces any previous verbal or written agreements. I certify that I have had the opportunity to ask questions, understand the procedure and its risks, and consent to proceed with the treatment at my own discretion.
*
Yes
Other
Parental Consent First and Last Name
Client Consent First and Last Name
*
Submit
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