Lash Lift & Tint Waiver & Consent Form

1

Name:* This field is required.

First Name

Last Name

2

Birthday:* This field is required.

Date

3

Email:If you want a copy of this form.

example@example.com

4

Cell Phone Number: * This field is required.

Area Code

Phone Number

6

Please Choose Which Service You are Scheduled For:* This field is required.You may need to fill out multiple forms (ie; if you are also getting a Brow Wax/Tint, you will need to fill out the Brow Form)

Lash TintLash Lift (with or without Tint)

7

Have You Had a Lash Lift Before? * This field is required.

YESNO

8

Please select any of the following that apply:* This field is required.

Previously had an allergic reaction to a lash tint

Dry Eye Syndrome

Sjorgen's Syndrome

Currently having Chemotherapy

Ocular Rosacea

Contacts

Lash Lift within the last 8 weeks

None of the above

Other medical condition that could be affected by laying with eyes closed for extended period (list below)

9

Please read and acknowledge the following agreement, and check the "I Agree" box to continue. Date and signature required on following pages.* This field is required.

11

Please read and acknowledge the following agreement, and check the "I Agree" box to continue. Date and signature required on following pages.* This field is required.

12

Today's Date* This field is required.

Date

13

Signature* This field is required.

14

Signature* This field is required.

Clear