EYELASH LIFT & TINT CLIENT INFORMATION FORM

Appointment Date:

Date Of Birth:

Have you ever had a Lash Perm (Lash Lift)? If YES, when did you have your last lash perm/lift?
YesNo

If YES, was it a good experience? If NO, please describe:
YesNo

Have you had a lash/brow tint before?
YesNo

If YES, did you experience any reaction to the tint?
If YES, please describe:
YesNo

Which best describes the look you would like to achieve for your lashes?
Fully LiftedIn BetweenSoft Natural Curl

CLIENT INFORMATION Continued

For a more effective, personalized treatment, please be as accurate as possible when filling out the following information

PLEASE CHECK ANY OF THE FOLLOWING THAT MAY APPLY TO YOU:

RELATING TO THE EYE
Eye surgeryEye illness or injuryDry eyesSeasonal allergiesEye infectionPermanent eye make-upBlepharoplastyBlepharitis (inflammation of eyelids)Allergies to adhesives found in band-aids or medical tapeAllergies to preservatives in salinesolutionsSensitivity or claustrophobia when your eyes are closed for long periods of timeRetinoids used to treat acne and skin problems (such as accutane or retin a)

GENERALLY RELATING TO EYELASHES
Hormone imbalanceRecent severe illness or injuryPregnancy or recent childbirthNew prescriptions or recently prescribed oral contraceptivesTypes of medical conditions that may contribute to hair and eyelash loss: hyperthyroidism or hypothyroidism, alopecia areata, lupus, diabetesVitamin and mineral deficiencies that may contribute to hair and eyelash loss: A, F, B, Selenium, Zinc, IronTrichotillomania (hair pulling disorder)Medications that may contribute to hair or eyelash loss: chemotherapeutic agents used in cancer treatment, Anticoagulants (blood thinners), beta blockers (used to control blood pressure)

CONSENT FOR LASH LIFT & TINT

I UNDERSTAND /AGREE TO THE FOLLOWING COMPLE TELY: (PLEASE INITIAL EACH STATEMENT)

I agree to have an eyelash lift (perm) and/or eyelash tint applied to my natural eyelashes and/or retouchedI consent to the procedure of an eyelash perm/lift or eyelash tint.I understand there are risks associated with having an eyelash perm and/or eyelash tint.I 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 that I will contact my technician and consult a physician at my own expense.I understand that even though my technician lifts/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 physician’s follow up care.I understand and agree to the care instructions provided by my technician for the use and care of my permed and/or tinted eyelashes.I realize and accept the consequences of failure to adhere to the aftercare instructions may cause the eyelashes to not stay permed as long as told.I understand and consent to having my eyes closed and covered for the duration of the 45-60 minute procedure.I release my technician from all liability associated with this procedure, 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.I understand there are no guarantees for length of time the lashes will stay permed.I understand the aftercare instructions and will do my part to maintain my results.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.

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

Patient Name:

Date:

Signature: