Lifts-Tint-Henna

1

Name

First Name

Last Name

2

Cell Phone

Area Code

Phone Number

3

E-mail

4

Which treatments are you receiving

Lash Lift

Tinting

Henna

6

Current Medications (please N/A if none)

7

Have you had any of the following procedures done?

Tinting

Lash Perm/Lift

Lash Extensions

Brow Henna

8

Did you experience any reaction to these treatmentsIf unsure, please let your provider know.

Yes

No

9

Section 2 - Lash Tint

10

Is this your first treatment?

Yes

No

11

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

Yes

12

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

13

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

Yes

14

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

Yes

15

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

Yes

16

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).

17

E-Signature* This field is required.

18

Today's Date* This field is required.

Date