Elite Lashes
Elite Lashes
Lash Lift & Tint Agreement and Consent Form
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Today's Date
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Full Name
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First
Last
Phone
Email
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How Did You Hear About Us?
Google
Facebook
Instagram
Words by mouth?
Do you taking any medications?
If yes, please list
Have you had eyelash or brow tinting, eyelash perming, eyelash extensions or semi-permanent mascara applied previously?
If yes, which treatment?
Did you experience any reaction to these treatments?
If yes, which treatment? and Please provide details of this reaction:
Did you seek medical advice from a doctor or specialist because of this reaction?
If Yes, what was the advice of your doctor/treatment given
Disclaimer
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Waiver of Liability
Section 1
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I understand there are risks associated with having a lash lift (perm) and / or tint applied to my eyelashes and that notwithstanding the utmost of care in the application of these products, there still exist risks associated with the procedure and product itself, which include, without limitation, eye irritation, eye pain, discomfort, hair loss and, in rare cases, blindness when improperly handled. As part of this procedure, I understand that a certain amount of eyelash adhesive material will be used to affix my eyelashes to a perm rod. Even though the Professional may apply or remove my lashes from the rod properly, I understand adhesive material may become dislodged during or after the procedure, which may irritate my eyes or require further follow - up care, at my own expense to prevent damage to my eyes.
Section 2
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I understand that my esthetician has the right to refuse services if unsanitary conditions exist and/or contagious infections.
Section 3
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I understand that there are many factors that may affect the life of the eyelash lift such as water and moisture contact, weather conditions, and activities involving exposure to high temperatures.
Section 4
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I understand that there are many factors that may affect the life of the eyelash lift such as water and moisture contact, weather conditions, and activities involving exposure to high temperatures.
Section 5
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I understand and agree to the care instructions provided by my therapist for the use and care of my eyelashes. I realize and accept the consequences of failure to adhere to these instructions may cause the eyelashes to not stay permed if told.
Section 6
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I release my professional from all liability associated with any injuries and/or current or future conditions resulting from the procedures.
Section 7
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I agree to the Waiver of Liability.
Section 8
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I agreed to No refund for any reason.
Section 9
I hereby grant the eyelash artist the full right to take, publish pictures of me, my face, my eyes and/or eyelashes, both before and after this procedure, for any advertising, education, including the right to retouch these pictures as deemed necessary by the eyelash artist. I further expressly assign any copyright in these pictures to the eyelash artist. I also grant my consent for the eyelash artist to use my image and likeness as contained in these pictures for any advertising or other purposes.
Permission to Use Photos
Section 10
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I have read and completed Client Intake Form in its entirety and in truth I acknowledge that I have been advised of the potential harmful or negative side effects that may occur to those who have specific medical or skin conditions.
No Known Medical Conditions / Informed Consent
Section 11
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I understand that the adhesives and adhesive remover are a skin, eye, and mucus membrane irritant and that in rare cases, persons may be allergic or have hypersensitivity to synthetics, cyanoacrylate, or formaldehyde which in small amount may be present in the adhesive.
No Known Medical Conditions / Informed Consent
Section 12
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I understand that the procedure requires that I lay still for up to 1 hour or longer with my eyes shut, and that if I wear contacts, I must remove my contacts lenses for the duration of the procedure.
Section 13
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I further state that I have no known medical condition that might be aggravated by the procedure or any medical condition that would prevent me from complying with or heeding to the eyelash artist's instructions or these warnings.
I have and agreed with all sections and statements above
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Clear Signature
Date Signed
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Submit