Lash Lift Intake/Consent Form
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Appointment Date:
*
-
Month
-
Day
Year
Date
PersonalInformation:
Are you 18 yrs or older?
*
Yes
No
Have you ever had lash lift?
*
Yes
No
If so, have you had any reactions?
Have you ever had an allergic reaction to hair perming products?
*
Yes
No
If so, have you had any reactions?
Will you be getting a lash tint with your lash lift?
*
Yes
No
If you answered yes, have you ever had any reactions after getting a lash tint?
Have you recently tinted your lashes?
*
Yes
No
If yes, when was the last time you got them tinted?
Do you currently have any other lash or brow procedures? (lash extension, brow tint, etc.)
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Yes
No
If so please describe:
Do you do any of the following to your lashes?
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Curl
Mascara
Lash serum
Other
None
Medical History:
Do you have skin sensitivity or allergies?
*
Yes
No
If so, please explain:
Are you taking any skin medication?
*
Yes
No
Are you pregnant or breastfeeding? If you answered yes, then we will not be able to proceed with the Lash Lift.
*
Yes
No
Do you have any of the following conditions? (please selectall that apply)
*
Blood Clots
Diabetes
Cancer/Chemotherapy
Dye Eye
Eczema
Epilepsy
Fungal Issues
Hepatitis
HIV/AIDS
Immune Disorder
Lupus
Ocular Rosacea
Ultra-Sensitive Skin
None
Are you currently being treated for an eye illness, eye injury, or skin condition?
*
Yes
No
If so, please describe:
Do you wear contact lenses?
*
Yes
No
If yes, do agree to remove your contacts during your procedure?
*
Yes
No
I don't wear contact lenses
Do you have frequent irritated, itchy, or watery eyes?
*
Yes
No
Are you currently on any blood thinners?
*
Yes
No
Are you allergic to perms, hair color or tape?
*
Yes
No
List all other allergies:
Terms &Conditions
I agree to receive a lash lift and/or tint from Elsa, to be applied to my natural eyelashes.
*
Yes, I understand and agree.
I understand that there is no guarantee of how long my lashes will remain curled or tinted.
*
Yes, I understand and agree.
I understand and agree that in rare occasions there are risks associated with having the chosen service performed on me.
*
Yes, I understand and agree.
I understand and agree that in rare circumstances eye or skin irritation & discomfort might occur.
*
Yes, I understand and agree.
I understand, I will not hold Elsa responsible in any way for any damages or issues that may arise as a result of having any of the services performed on me.
*
Yes, I understand and agree.
I understand and agree that in rare circumstances eye or skin irritation & discomfort might occur.
*
Yes, I understand and agree.
I understand to not wear my contact lenses during this procedure.
*
Yes, I understand and agree.
I understand I may not wet, steam, or put on mascara for at least 24 hours after the service is performed.
*
Yes, I understand and agree.
I consent to having my eyes closed for 30-45 minutes.
*
Yes, I understand and agree.
I am aware I might need 1-2 sessions for a lash lift to get more of a curl on my natural lashes.
*
Yes, I understand and agree.
I understand maintenance for lash lifts are every 4-6 weeks.
*
Yes, I understand and agree.
I understand and agree not to bring any guests to my appointment.
*
Yes, I understand and agree.
I understand and agree to reschedule/cancel my appointment 24 hrs. before my scheduled appointment.
*
Yes, I understand and agree.
I understand and agree that this agreement will remain in effect for this procedure and all future procedures completed by Elsa for up to a year.
*
Yes, I understand and agree.
I use Instagram (@bareskinglowstudio) for promotional proposes. Do you consent photos/videos during your service?
*
Yes
No
By signing below, I agree to the following:I have completed this form to the best of my ability and knowledge. I agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform Elsa (Bare Skin Glow Studio) of any discomfort I may experience at any time during my treatment to allow her to adjust accordingly. I agree to waive all liability toward my technician Elsa (Bare Skin Glow Studio) for any injury or damages incurred due to any misrepresentation of my health.
Today's Date
*
-
Month
-
Day
Year
Date
E-Signature:
*
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