Confidential Client Intake Form

Lash Lift/Tint Treatments Indemnity/Informed Consent

Includes Lash Lift, Lash Lift with Eyelash Tint, and Eyebrow Tint treatments
Please read the following carefully. Should you require more information before completing this form please stop and contact me at Bloom Bar so I can personally answer any questions you may have.
I authorize Bloom Bar LLC, Tracey Coleman Esthetician, to perform the Lash Lift (Perm) and/or Eyelash Tint and/or Eyebrow Tint procedure applied to my natural eyelashes and Eyebrows and/or retouched by signing this agreement below. Further, I hereby consent to any “before and after” photographs, which may or may not be used for the purposes of advertising or promotion of services.*

I Understand and Agree
I understand that the lashes will be curled with an advanced solution and a conditioning cream and understand and consent to having my eyes closed and covered for the duration of the 45-90 minute procedure*

I Understand and Agree
I understand there are risks associated with having an Eyelash Lift (perm) and/or Eyelash/Eyebrow Tint treatment. I further understand that as part of the procedure, eye irritation, eye pain, eye itching, discomfort, and in rare cases eye infection, swelling or blurriness could occur. I agree that if I experience any of these conditions with my Lashes, Eye area or or Eyebrows that I will inform my Esthetician and consult a physician at my own expense.*

I Understand and Consent
I understand that even though my Esthetician performs the Eyelash Lift (perm) and/or Eyelash/Eyebrow Tint procedure using the proper technique, the instruments, tapes, cleaners, gel pads, adhesives, and removers used may irritate my eyes or require a physician’s follow-up care. Further, I understand that if at any time I, the Client, or the Esthetician are uncomfortable with the Eyelash Lift (perm) and/or Eyelash/Eyebrow Tint treatment, I will inform the Esthetician who will gladly rectify the problem, including ending the session.*

I Understand and Consent
I understand there are no guarantees, warranties, promises, commitments or refunds and acknowledge that I have no particular representation or guarantees, and I am consenting to the Eyelash Lift (perm) and/or Eyelash/Eyebrow Tint treatment at my own risk. Further, I understand that all conditions must be revealed or disclosed by me to my Esthetician regarding health history, medications being taken and any past reactions to products used.*

I Understand and Consent
I understand and consent to the Eyelash Lift (perm) and/or Eyelash/Eyebrow Tint treatment being carried out without undergoing a sensitivity patch test. Further, should I wish to request a complimentary sensitivity patch test I understand I need to inform my Esthetician in advance to arrange an appointment at least 24 hours prior to the date of the scheduled Eyelash Lift (perm) and/or Eyelash/Eyebrow Tint treatment to have this test performed. The sensitivity patch test, when conducted, may indicate my sensitivity/allergy to the products used.*

I Understand and Consent
I am 18 years or older*
**If you are under the age of 18 please contact me at 808 206 9337 for a Parent/Guardian Informed Consent/Indemnity on behalf of a Minor Form which will need to be completed prior to your appointment.
Printed Name*

First NameLast Name
I, the client herein signed below and whose name is printed above, certify that I have read and fully understand the above waiver and release form. I also certify that I have provided information regarding my health and medications taken to the best of my knowledge, and hereby release, give up, acquit and discharge Bloom Bar LLC, Tracey Coleman Esthetician and or anyone affiliated thereto including any partnership, property, corporations or company associated with said individual from any claims or damages of any nature. 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 these products and service(s).*

Clear

Parent/Guardian Indemnity/Informed Consent For Minor

(required in addition to signed Client Indemnity/Informed Consent if client is a minor)
Printed Name

First NameLast Name
Phone Number

Area CodePhone Number
I, the Parent/Guardian of the individual/client receiving the treatment herein signed below and whose name is printed above, certify that I have read and fully understand the above waiver and release form. I also certify that I have provided information regarding my health and medications taken to the best of my knowledge, and hereby release, give up, acquit and discharge Bloom Bar LLC, Tracey Coleman Esthetician and or anyone affiliated thereto including any partnership, property, corporations or company associated with said individual from any claims or damages of any nature. 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 these products and service(s).

Clear

Have you used or been prescribed any medications (topical or oral) for acne / acne control?*
If yes, please specify what and date last used
Are you a smoker?*
If yes, how many cigarettes/other per day?
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)*
Have you ever experienced claustrophobia?*
Female Clients
Are you taking birth control?*
If yes, what kind?
Are you pregnant or trying to become pregnant?*
Any menopause issues?*
If yes please specify
Are you undergoing any hormone replacement therapy?*
If yes please specify
Male Clients
What is your current shaving system?
Do you experience irritation from shaving?
Post Facial Care / Waxing Instructions (if applicable): Aerobic exercise and/or vigorous physical activity should be avoided for 48 hours. Direct sunlight exposure is to be avoided immediately following the treatment (including any strong UV light exposure and/or tanning beds). If some sun exposure cannot be avoided first apply a broad spectrum sunscreen of SPF 30. Sunscreen (with a minimum SPF15) should become part of your daily skin care regimen as skin can potentially become more sensitize to the sun as a result of this treatment. Unless otherwise specified, in the evening following your treatment, cleanse your skin with a mild cleanser and water followed by a non-active moisturizer. Do not apply additional exfoliating ingredients/products the day of your service as over exfoliation can result in irritation or further sensitivity. Consult your skin care professional before resuming topical treatments. Enzyme peels, DermaFile or DermaDisc treatments, chemical peels or facial waxing can result in skin flushing/redness or slight skin flaking or sensitivity for up to 48-72 hours post treatment. DO NOT peel, pick, rub, or scratch your skin at any time, whatsoever. This can potentially cause damage or compromise your results.

I have read the post car instructions and agree to adhere to them
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release Bloom Bar LLC, Tracey Coleman Esthetician and all related entities products and property from liability and assume full responsibility thereof.

Yes, I understand

Confidential Client Intake Form

Lash Lift & Tint Service

Lash Lift/Tint Treatments Indemnity/Informed Consent

Parent/Guardian Indemnity/Informed Consent For Minor

Skin Care Consultation Form

Your Skin

Your Health

Female Clients

Male Clients

Facial Treatments Indemnity/Informed Consent