Informed Consent for: Lash Lift & Lash Tint
By LashwithG
Name
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First Name
Last Name
Phone Number
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Format: (000) 000-0000.
Email
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example@example.com
Emergency Contact
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First Name
Last Name
Emergency Contact Phone Number
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Format: (000) 000-0000.
Please read the following
You must be over 18 to consent to services. You must be over 16 to receive services. Under 18 requires parental signature
I am over 18
I am under 17 and will require a parental signature
Have you ever used hair color before?
Yes
NO
Have you ever had your lashes lifted or tinted?
Yes
NO
I agree to have eyelash lift and/or eyelash tint applied to my natural eyelashes and/or a retouch and I do understand that I may not be a candidate for a lash lift if I have damaged lashes or lashes with gaps or have extremely short natural lashes.
*
Please Select
YES
We need to discuss this first
We suggest checking with your doctor prior to having a lash lift and/or lash tint if you: are pregnant, nursing, have chronic dry eye, conjunctivitis, eye infections, trichotillomania, have recently undergone chemotherapy, or have recently had Lasik or blepharoplasty surgery.
Yes, I am ready to go.
NO
I understand that there are risks associated with having any of these procedures. I further understand that as part of the procedure eye irritation, eye pain, eye itching, discomfort, and in rare cases, eye blurriness or infection can occur. I agree that if I experiences any of these conditions with my lashes, I will contact my technician and consult a physician at my own expense.
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Please Select
YES
NO
I understand that though my technician uses proper technique, instruments, adhesive, tape, cleansers, eye gel pads, and removers, my eyes may become temporarily irritated or in rare cases, require a physician’s care. I release my technician from all liability associated with the procedure(s), 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.
*
Please Select
YES
NO
I understand and agree to the care instructions provided by my technician for the use and care of my eyelash lash lift and/or lash tint. I understand and accept the consequences of failure to adhere to these instructions, and that it may causes the lashes to not perform at optimal level. *** Please check all boxes off to confirm you have read them and understand.
Do not sleep on your lashes for the first 24 hours
Avoid rubbing, or playing with your lashes, resist the temptation to touch
Waterproof mascara may be used, but the removal may decrease the lift. Regular mascara is recommended
No water, sweat, steam, saunas or make-up for the first 24 hours
I understand that these procedures are semi-permanent and that my natural lashes will continue to grow and fall out normally, making touch-up appointments necessary to maintain the original look of the procedure(s). Most clients require a appointment every 3-4 weeks. There are no guarantees for the length of time your procedure will last. Please follow the instructions above for best results.
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Please Select
I Understand - Yes
Please speak to me - NO
I understand that additional conditions could occur or be discovered during the procedure. I agree that if at any time, I am uncomfortable with the lash lift and tint treatment, I will inform the technician and she will gladly rectify the problem, including ending the session.
*
Please Select
YES
NO
I understand and consent to having my eyes closed for the duration of approximately 60 minute procedure and that it is my responsibility to keep them closed and remain still during this time. Procedure times vary. *
*
Please Select
YES
NO
I consent to Before and After photographs for purpose of documentation purposes.
*
Please Select
YES
NO
I consent to you publishing and reproducing photographs of me, my face, and/or my eye area, both before and/or after the procedure
*
Please Select
YES
NO
I understand that it is imperative that I disclose all information requested in the provided Aesthetics Confidential Client History.
Do you currently use contact lenses and agree to remove them during application
*
Please Select
YES
NO
Current use of eyedrops of any kind
*
Please Select
YES
NO
Current allergies to anything that could cause my eyes to water or blink to excess
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Please Select
YES
NO
History of recurrent eye or tear duct infections
*
Please Select
YES
NO
History of dry eyes or Sjogren’s Syndrome
*
Please Select
YES
NO
Other conditions affecting the procedure
*
Please Select
YES
NO
I confirm that I have NOT been in close contact with someone who has tested positive for the novel coronavirus or someone who has been required to self-isolate within the last 10 days.
*
Please Select
YES
NO
I understand the cancellation policy as follows: *** Please check all boxes off to confirm you have read them and understand.*
Cancellations must be made prior to 24 hours before scheduled appointment. If cancelled within 24 hours of appointment a cancellation fee will be due immediately.
If I fail to arrive to my appointment and give no notice I will be billed for 100% of the services cost
Services are Non-Refundable
If you have any questions please feel free to leave them here to discuss upon arrival or you can call me to discuss prior to the visit.
By Signing below, I verify the information I have provided on this consent form is truthful and accurate. I knowingly and willingly consent to having treatment.
*
Please Select
I consent fully - Yes
Please discuss options - NO
This agreement will remain in effect for all lash lift and/or tinting procedures performed. I read English and understand that this agreement is legal and binding. I will not hold LashwithG or any of its service providers liable for any damages on this day or any day forward. I have read and understand all information in this agreement. I am over 18 years of age and consent to this agreement and to the services rendered.
Todays Date
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Please sign acknowledging the above document.
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