EYELASH LIFT CONSULTATION FORM

Eyelash Lift Consultation Form

I agree to have an eyelash lift (perm) and/or eyelash tint applied to my eyelashes and/or retouched. By signing the agreement I consent to the producer of an eyelash perm or eyelash tint by my therapist.

I understand there are risks associated with having an eyelash perm and/or eyelash tint. I further understand that as part of the procedure, eye irritation, eye pain, eye itching, discomfort and in rare cases eye infection or blurriness could occur. I agree that if I experience any of these medical conditions with my lashes the I will contact my therapist and contact my therapist and consult a doctor at my own expense.

I understand that even though my therapist perms the lashes using the proper technique, the instruments, tapes, cleaners, eye gel pads, adhesives and removers used may irritate my eyes or require a doctors follow-up care.

I understand and agree to the care instructions provided by my therapist for the use and care of my permed and/or limited eyelashes. I realise and accept the consequences of failure to adhere to these instructions may cause the eyelashes to not stay permed as long as told.

I am informing my therapist of the following conditions by marking with a check:

Current use of contact lenses which I agree to remove during application

Current use of anything such as oil-containing sunscreen or moisturizers around the eyebrow

Current use of eyedrops of any kind, prescription or over-the-counter medication

Current allergies or sensitivities to instruments, fumes, tapes, cleaners, adhesives, and removers that could cause my eyes to water and blink in excess

History of dry eyes or Sjogren’s Syndrome

Recent history of Chemotherapy or any other medical conditions which would prohibit or compromise the process and retention of this eyelash perm

You are pregnant or a possibiltiy you may be.

I agree to the following eyebrow Lift/Tint perm post-op and maintenance instructions:

No water can come in contact with the eye area for 24 hours after the application
This agreement will remain in effect for this procedure and all future procedures conducted by my therapist.

I am over 18 years of age and consent to the agreement and to treatment.

There are no guarantees for length of time the eyebrows will stay permed. I understand the aftercare instructions and will do my part to maintain my eyebrows. I understand that there are many factors that may affect the life of the eyebrow Lift /Tint such as water and moisture contact, weather conditions, and activities involving exposure to high temperatures.

By signing below, I verify that I have read and understand the above statements and agree to them.

What’s your first name?

What’s your email address?

Date of patch test

What’s your last name?

What’s your phone number?

I can confirm I've received no adverse reactions within 48hrs of the patch test.

YES

Your Signature