Glam Body Sugaring Boutique Lash/ Brow Enhancement Consent Form

Glam Body Sugaring Boutique Lash/ Brow Enhancement Consent Form
Name

First NameLast Name
Address

Street Address

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CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
E-mail
Date of Birth

MonthDayYear
Referred By:
Do you have any allergies?
Have you ever had a Lash Lift or Lash Perm?
If yes, was it a good experience?
If NO, please explain:
When was your LAST Lash Lift?
Have you ever used strip lashes or lash extensions and experienced burning, swelling ,itching of eyes/lids?
Have you ever had a Lash or Brow Tint before?
If yes, did you experience any reaction to the tint?
Are you currently receiving any treatment(s) for eye injury or illness?
Please list any eye drops that you are using (prescription or over the counter) below:
Medical History, Please check all that apply

Cataract SurgeryChemotherapy/RadiationContact LensesDry Eyes/Sjorgen's SyndromeAllergies/Watery EyesPermanent MakeupLasik Eye SurgeryGlaucomaCompulsive Eyelash PullingAlopeciaLash LossNursingPregnantAllergies to Adhesive TapeBlepharitisBlepharoplastyPink Eye/StyeRecent medical treatment to the eyes, lids or ducts
Other Medical Allergies:
INFORMED CONSENT FOR LASH LIFT

I am over the age of 18, am not under the influence of drugs or alcohol, am not pregnant or nursing and desire to receive the indicated Lash Enhancement Treatment.

» I agree and consent to have an eyelash lift/enhancement and/or eyelash tint applied to my natural lashes and/or retouched by Glam Body Sugaring Boutique LLC.

» I understand and agree to the care instrictions provided by the Glam Body Sugaring Boutique LLC professional for the treatment of lifting lashes and/or tinting lashes. I realize and accept the consequences of failure to adhere to these instructions may cause the lashes to not stay lifted. I agree to not wet my lashes for 48 hours.

» I understand that although Glam Body Sugaring Boutique LLC may enhance my lashes using proper technique, the instruments, shields, cleansers, eye gel pads, lift solutions, and color tints may irritate my eyes or require a physicians care at my own expense.

» I understand there are risks associated with having my eyelashes enhanced and/or tinted. I further understand that as part of the procedure, eye irritation, eye pain, eye itching, discomfort amd in rare cases eye infection or blurriness may occur. I agree that if i experience any of these conditions DURING or AFTER my procedure, I will contact Glam Body Sugaring Boutique LLC and consult a physician at my own expense. I release my technician and Glam Body Sugaring Boutique LLc from all liability associated with this procedure, which is performed with the utmost attention to care, safety and proper application using tools and products that the lash specialist has been professionally trained to use.

» There are a small number of individuals who may have an allergic reaction to tints, hair dyes and other chemical treatments. It is only in rare situations that the reaction can be severe. If you've ever gotten a rash from an allergic reaction to henna or to hair dye containing para-phenylenediamine(PPD), then you may also develop an allergic reaction to lash or brow dyes and should not use them. We offer a complimentary patch test service for all of our clients. Please request an additional patch test if you would like to check your sensitivity, which should be performed 48 hours PRIOR to your tinting experience. We thank you for your cooperation to ensure your comfort and safety.

» I request that my eyelashes and/or eyebrows be treated with Lash & Brow tinting and or Lash Lift Products. I also request and consent to this/these procedure(s) being carried out without undergoing a sensitivity patch test. The sensitivity test, which if conducted, may indictate my sensitivity/allergy to the product(s).

» This aggrement will remain in effect for the procedure and all future procedures conducted at Glam Body SUgaring Boutique LLC and its subsidiaries for ONE year from the date of this signed form. I understand it is my responsibilty to advise my lash specialist of any changes in the future that may affect my suitability for procedures to be undertaken any time in the intervening 12 months. I understand that this agreement is binding and that I have read and fully understand all information listed above. I represent that I am over the age of 18 years. If below 18 years of age a parent or guardian must also sign this form and accompany you to your appointment.

I understand that it is imperative that I remove all eye makeup prior to my appointment. If I do not remove all eye makeup at least one hour prior to my appointment, I may be asked to reschedule my appointment. Cancellation fees may apply.

I understand that I was notified that I cannot use an eyelash curler for one week prior to service.

I give Glam Body Sugaring Boutique LLC permission to perform my eyelash lift and/or eyelash tint and/or eyebrow tinting procedure.
Lash/ Brow Enhancement Phote Release Agreement

I hereby consent to, and authorize the use by Glam Body Sugaring Boutique LLC of the specified eyelash and or eyebrow photographs and/or video; that is, photographs taken before, during and after my lash and or brow procedure.

I understand that my identity will be protected and neither my full face nor my name will be used in conjunction with the photographs and/or video.

Glam Body Sugaring Boutique LLC has explained that all the photos and/or videos will be clinically appropriate and tastefully presented.

I have agreed on the photographs that Glam Body Sugaring Boutique LLC to be used and it is understood that these photos may be used on Glam Body Sugaring Boutique LLC web site, social media accounts (Facebook, Instagram, Twitter), and in-office for demonstrational and promotional purposes. I understand that I am not entitled to compensation for these photos being used.

Should I desire to revoke permission for their use in the future, I understand that I must notify Glam Body Sugaring Boutique LLC in writing and allow 30 days to accomplish this removal.

I now release, Glam Body Sugaring Boutique LLC and anyone authorized by ,all personal rights Glam Body Sugaring Boutique LLC objections I have or may have to the above described uses of my photographs and/or videos. I have entered into this release freely or voluntarily, and agree to be bound thereby.
IMPORTANT- Please let your Esthetician know if you're claustrophobic in any way prior to your service.
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