D'Luxx Lashes "YUMI Lashes" Waiver Form

Date of Treatment*

Date

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Email*

example@example.com

Date of Birth*

Date

How did you hear about YUMI Lashes?*

Why do you want YUMI Lashes?

Have you already received this treatment?*

What are your expectations?

Have you recently had an eyelash dye or perm?*

Please select if you have any of the following*

If you have any other eye disease or allergy not stated above please describe*

Are you currently taking any medications?*

YESNO

Please list any medications currently taking*

Are you pregnant or lactating?*

YESNO

YUMI LASH LIFT WAIVER AND RELEASE FORM

I authorize D'Luxx Lashes to perform the Yumi Lash Lift procedure.

I understand that there are risks associated with the YUMILashes Keratin Lash Lift procedure.
I understand that as part of the procedure, eye irritation, pain, itching and discomfort may occur.
I understand and agree to follow the aftercare instructions provided by my technician.
I understand that failure to follow the aftercare instructions may cause an undesirable result.
I understand that my eyes will need to be closed for a duration of up to 60-90 minutes during the procedure.

I understand this procedure requires my lashes to be glued to a silicone pad with a water based adhesive and lifted with an advanced solution onto a silicone pad, conditioning cream, Tint (optional) and nourishing oil.

I understand that it is my responsibility to be still during the procedure and to keep my eyes closed during the process unless otherwise advised.
I understand that opening my eyes at any point during the procedure is not recommended and may cause an undesirable result. I agree to keep my eyes closed throughout the procedure unless instructed otherwise by my technician.
I have been fully informed as to the methods and procedures concerning the Lash Lift procedure. The risks of the cosmetic procedure I have chosen have been disclosed to me. Although rare, some may result in complications such as transient eye redness and irritation and allergic reaction to the products used to lift the lashes and/ or the tape, anti- wrinkle gel patches or black eyelash tint. If at any time I (or the technician) are uncomfortable with the Lash Lift procedure, I will inform the technician and we will gladly rectify the problem, including ending the session if I (or the technician) wish.
It has been represented to me that no guarantees, warranties, promises, commitments or other statements as to the results of this treatment have been made.

I acknowledge that I have no particular representation or guarantees, and I am consenting to the procedure at my own risk. All conditions must be revealed or disclosed by me to the technician regarding my health history, medications being taken and any past reactions to products used or medications taken. Additional conditions could be discovered during the procedure, which could affect my ability to tolerate the procedure.
This agreement will remain in effect for this procedure and all future YUMILashes Keratin Lash Lift procedures conducted by my technician or any other technician conducting business at the salon/spa listed below. I understand this agreement is binding and that I have read and fully understand all information above.
I release my technician or salon/spa D'Luxx Lashes and or anyone affiliated, from all liability associated with this procedure, 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.

By signing below, I verify that I have read and understand the above statements and agree to them. I also consent to “before and after” photographs, which may or may not be used for the purposes of advertising.

I have read D'Luxx Lashes waiver and release form and understand all the information provided to me.*

I AGREE

Signature*