KOREAN LASH LIFT & TINT CONSENT FORM
Esthetician: Jasmine Marenco
CLIENT INFORMATION
FIRST NAME
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First Name
Last Name
AGE
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DATE
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Month
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Day
Year
Date
ADDRESS
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
POSTAL CODE
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PHONE
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Format: (000) 000-0000.
EMAIL ADDRESS
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example@example.com
BIRTHDAY
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Month
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Day
Year
Date
EMERGENCY CONTACT
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HOW DID YOU HEAR ABOUT US?
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HAVE YOU EVER GOTTEN A LASH LIFT BEFORE?
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YES
NO
IF YES, HOW LONG AGO WAS YOUR RECENT LASH LIFT?
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MEDICAL HISTORY Please check any of the following that may apply to you
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Known Allergies or Sensitivities to Lash Lift Adhesive or Product
Known Eye Condition (ex. Dry Eye Syndrome)
Sensitive Eyes
Recent Eye or Eyelid Surgery
Conjunctivitis (Pink Eye)
Pregnant or Breastfeeding
Recent Semi-Permanent Makeup
On regular Medications and/or Supplements
None
If you selected yes to any of the above, please specify or if not, put N/A :
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DO YOU HAVE ANY OTHER ALLERGIES OR MEDICAL CONDITIONS NOT LISTED ABOVE THAT WE SHOULD KNOW ABOUT?
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YES
NO
PLEASE SPECIFY, IF NOT, PUT N/A
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DO YOU USE ANY LASH SERUMS OR PRODUCTS THAT ENHANCE GROWTH ON YOUR NATURAL LASHES?
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YES
NO
PLEASE SPECIFY
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DO YOU WEAR CONTACT LENSES?
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YES
NO
IF YES, DO YOU AGREE TO REMOVE THEM DURING THE LASH LIFT PROCEDURE?
YES
NO
I HAVE COMPLETED THIS FORM TRUTHFULLY, AND TO THE BEST OF MY KNOWLEDGE. I AGREE TO INFORM THE TECHNICIAN OF ANY CHANGES.
Printed Name
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Signature
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Date
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Month
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Day
Year
Date
Back
Next
I, _________________________, GIVE PERMISSION TO THE LASH TECHNICIAN TO PERFORM THE FOLLOWING LASH PROCEDURES:
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LASH LIFT
LASH LIFT & TINT
LASH TINT
LIFT RETOUCH
CONSENT & LIABILITY
WE TAKE ALL PRECAUTIONS TO ENSURE YOUR SAFETY AND WELLBEING BEFORE, DURING AND AFTER YOUR SERVICE. Please read carefully and initial beside each statement
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I ACKNOWLEDGE THE POTENTIAL RISKS ASSOCIATED WITH UNDERGOING A LASH LIFT AND/OR LASH TINT SUCH AS, BUT ARE NOT LIMITED TO: EYE IRRITATION, EYE ITCHING, EYE DISCOMFORT, AND, IN RARE CASES, ALLERGIC REACTIONS.
IN THE EVENT THAT I FEEL UNCOMFORTABLE DURING THE TREATMENT, I COMMIT TO INFORMING THE TECHNICIAN PROMPTLY, AND THEY WILL ADDRESS THE ISSUE, INCLUDING THE POSSIBILITY OF TERMINATING THE SESSION.
I CONSENT TO KEEPING MY EYES CLOSED AND STAYING STILL THROUGHOUT THE DURATION OF THE PROCEDURE.
I UNDERSTAND AND ACCEPT THAT RESULTS AND THE LONGEVITY OF THE LASH LIFT AND/OR LASH TINT MAY VARY FROM CLIENT TO CLIENT, AND NO GUARANTEES ARE OFFERED OR IMPLIED.
I AGREE TO HOLD JAS'S LASHES & BEAUTY SERVICES LLC AND ALL AUTHORIZED REPRESENTATIVES HARMLESS FROM ANY LIABILITY RELATED TO THE LASH LIFT AND/OR LASH TINT PROCESS. JAS'S LASHES & BEAUTY SERVICES LLC AND THEIR STAFF HAVE EXPLAINED THIS PROCEDURE TO ME, AND ANY QUESTIONS I MAY HAVE HAD HAVE BEEN ADDRESSED.
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I AGREE TO HOLD JAS'S LASHES & BEAUTY SERVICES LLC AND ALL AUTHORIZED REPRESENTATIVES HARMLESS FROM ANY LIABILITY RELATED TO
THE LASH LIFT AND/OR LASH TINT PROCESS. JAS'S LASHES & BEAUTY SERVICES LLC AND THEIR STAFF HAVE EXPLAINED THIS PROCEDURE TO ME, AND ANY QUESTIONS I MAY HAVE HAD HAVE BEEN ADDRESSED.
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I GRANT JAS'S LASHES & BEAUTY SERVICES LLC PERMISSION TO TAKE AND PUBLISH PHOTOS AND/OR VIDEOS OF MY FACE, AND/OR MY EYE AREA, BOTH BEFORE AND AFTER FOR THE PURPOSE OF ADVERTISING AND MARKETING.
AFTERCARE
AFTERCARE IS ESSENTIAL IN MAINTAINING THE RESULTS AND LONGEVITY OF THE LASH LIFT AND TINT. I AGREE TO FOLLOW AFTERCARE INSTRUCTIONS PROVIDED TO ME. THIS CAN INCLUDE CONDITIONING THE LASHES DAILY, KEEPING THE EYELASHES AND EYE AREA CLEAN, AND NOT PICKING, PULLING OR RUBBING THEM.
Client signature:
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Date:
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Month
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Day
Year
Date
Parent/Guardian consent: If the client is under 18 years of age, the parent or legal guardian must provide consent.
Parent/Guardian signature:
Date:
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Month
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Day
Year
Date
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