Name *

First Name

Last Name

Phone *

(###)

###

####

Today's Date *

MM

DD

YYYY

I am informing my technician of any of the following contraindication conditions. *

Please read and check all that apply:

Current use of contract lenses which I agree to remove during application

Allergies or sensitivity to instruments, adhesive tape, fumes, cleansers, eye gel pads, or eye remover.

Current use of anything such as oil-containing sunscreen, or moisturizers around the eye.

History of eye or tear duct infection.

Current use of eye drops of any kind, prescription or otherwise.

Dry Eye Syndrome

Sjogren's Syndrome

Currently having chemotherapy

Ocular Rosacea

None

Please read and check each box below

I agree to have an eyelash lift (perm) and/or eyelash tint applied to my natural eyelashes and/or retouched. I consent to having my eyes closed and covered for the duration of the 45-60 minute procedure. By signing this agreement, I consent to the procedure of an eyelash perm or eyelash tint by my technician.

I understand there are risks associated with having an eyelash perm 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 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 using the proper technique, the instruments, tapes, cleaners, eye gel pads, adhesives, and removers used may irritate my eyes or require a physicians follow-up care.

I understand and agree to the to the care treatments provided