Lash LiftBrow LaminationBrow Tint Consent Form Name * First Name Last Name Phone Number * (###) ### #### Email * Please leave days/times that work best for your schedule * I am informing my technician of any of the following contraindicated conditions for the lash lift. Check all that apply Allergies to adhesive tape, fumes or eye remover Dry Eye Syndrome Sjorgen's Syndrome Currently having Chemotherapy Ocular Rosacea I am informing my technician of any of the following contraindicated conditions for the brow lamination. Check all that apply Currently having Chemotherapy Psoriasis Eczema Alopecia Sun Burn Ultra Sensitive Skin Wounds in the treatment area I consent to having my eyes closed and covered for the duration of the 45-90 minute procedure. * Yes No I wear contacts * Yes No I agree to have an eyelash lift, brow lamination and/or eyelash tint applied to my natural eyelashes and/or retouched. By signing this agreement, I consent to the procedure of an eyelash perm, brow lamination or eyelash tint by my technician. I understand there are risks associated with having an eyelash perm, brow lamination 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 understand that some mild but normal symptoms may occur with the brow lamiation depending on the sensitivity of my skin during the procedure and will subside in 24 hours. These symptoms may include: mild tingling, slight redness due to brushing the hairs, slight warmth in the area. 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 perms the lashes/brows using the proper technique, the instruments, tapes, cleaners, eye gel pads, adhesives, and removers used may irritate my eyes/brows 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/eyebrows. I realize and accept the consequences of failure to adhere to these instructions may cause the eyelashes to not stay permed as long as told. I agree to the following Post- Lash Lift: No water can come in contact with the eye area for 24 hours after the application. Avoid makeup such as mascara, eyeliner or brow pencil for the first 24 hours. Avoid using oil containing sunscreens, moisturizers and cleansers on lashes for the first 24 hours. Acknowledgement and Waiver I am over 18 years of age and consent to the agreement and to treatment or have a parent with me that consents to this service. This agreement will remain in effect for this procedure and all future procedures conducted by my technician. I read English and understand that this consent agreement is legal and binding. I have read and fully understand all information in this agreement. 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. 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 eyelashes. 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. Today's Date * MM DD YYYY I agree to photo consent. These photographs may be used on the Bliss Esthetics website or on social media. Please answer yes or no and add a signature on the place indicated below. Thank you. * Yes No Thank you! We look forward to seeing you!
