Lash Lift and Tint

Lash Lift and Tint
Name

First Name Last Name
Gender

Male Female
Birth Date

Month Day Year
Cell Phone

- Area Code Phone Number
Home Phone

- Area Code Phone Number
E-mail
Which treatments are you receiving

Lash Lift Lash Tint Both
Have you had any of the following reactions?

Skin Disorder Eye Infections Eye Disease Inflammation of the Skin Recent Eye Surgery Blephartitis Watery Eyes Hayfever Allergies Bell's Palsy Previous reactions to eye treatments Contact Lenses Latex/Band-Aid Allergy Allergies to adhesives, glues or bonding agents Allergies to Acetone Are you pregnant or lactating Are you on the contraceptive pill Are you taking HRT None
Current Medications (please N/A if none)
Other relevant information for provider
Have you had any of the following procedures done recently?

Tinting Lash Perm/Lift Lash Extensions Semi-Permanent Mascara
Did you experience any reaction to these treatments

Yes No
Section 2 - Lash Tint
Is this your first tint treatment?

Yes No
Are you tinting your:

Lash Brow Both Lash and Brow
I agree to disclose any and all necessary health information to reduce the risk of any abnormal reaction.

Yes
I agree to disclose to the esthetician the use of any topical and/or ingested medications that may interfere with the coloring agents which may cause irritation or adverse reaction.

Yes
I understand that I should avoid activities that will increase the likelihood of additional perspiration for a minimum of 4 hours after treatment.

Yes
I understand that excessive cleaning or rubbing will result in loss of color.

Yes
I understand that results are temporary will vary from treatment to treatment.

Yes
Agreement: I request and consent to these procedures being carried out today without undergoing a sensitivity patch test. The sensitivity test, which if conducted, may indicate my sensitivity / allergy to the products. I understand the contents of this form and take full responsibility for my actions, thus absolving all other parties of their responsibilities, if any, associated with the supply of the products and services(s).
E-Signature *
Today's Date *

- Month - Day Year
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