Lash Lift and Tint Intake Form
Sign in to Google to save your progress. Learn more
Email *
Name *
Untitled Title
Email *
Address, City, State, Zip *
Phone number *
Emergency Contact Name *
Emergency Contact Phone Number *
How Did You Hear about MT Brow Bar? *
Required
Who referred you? (MT Brow Bar offers a Referral Program)
I am over the age of 18 and not under the influence of any drugs or alcohol. (Place initials below)(Minors need a separate consent form signed by their guardian or parent. Please contact MTBB for more information) *
Are you pregnant or nursing? *
Pregnant/Nursing Clients:  I understand that hormones, while actively nursing or during pregnancy, may alter the outcome of my procedure. Should there be a reaction during or after my procedure certain medications may or may not be able to be given to treat said reaction.
Do you wear contact lenses? *
Contact Lens wearers please note: NO contacts on day of appointment. You may resume wearing contacts the following day. Please bring glasses to your appointment. *
ANY previous Permanent Makeup, Lash Lift, Last Tint, Brow Lamination, Brow Tint or Henna services?  If so which service and when? *
Were there any complications/reactions/sensitivities or generalized complaints from the above mentioned service? If yes, please describe
Do you have any big events coming up? Wedding, honeymoon, vacation, etc? Please explain and include date
Allergies *
Please list ANY medications/supplements (especially fish oil, krill oil, turmeric, etc) you are taking. If none please state "none" *
General Medical. Select any that apply *
Required
Other medical history not mentioned in previous section
Please check any of the following that may apply to you: *
Required
Tanning Bed Use *
Do you spray tan *
Last spray tan
History of COVID? Date of last COVID illness? *
Recent facial surgeries? List below, including date/year
Are you a fitness model/body builder?
Clear selection
Skin *
Required
Need a “Quiet Appointment”?  (Artist will be as quiet as possible during service to allow for the most relaxing experience possible)
Clear selection
I understand that I am required to submit a minimum of 3 photos of my brows or lashes (procedure area) without makeup to MTBB within 48 hours of booking my appointment OR 72 hours prior to my appointment(whichever is soonest).  Please initial below.Photos can be sent to 936-870-7021 or mtbrowbar@gmail.com *
I understand that this client questionnaire is required to be completed a minimum of 72 hours prior to my appointment(if possible).  Please initial below *
I consent to the procedure of an eyelash perm/lift or eyelash tint *
I understand there are risks associated with having an eyelash perm/lift and/or eyelash tint *
I 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 I will contact MT Brow Bar and consult a physician's follow-up care. *
  I understand that even though my technician lifts/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 physician’s follow-up care.  
 *
  I realize and accept the consequences of failure to adhere to the aftercare instructions may cause the eyelashes to not stay permed as long as told.  
 *
  I understand and consent to having my eyes closed and covered for the duration of the 60-90 minute procedure  
 *
  I release my technician from all liability associated with this procedure, which is performed with the utmost attention to safety and proper application using tools and products that the technician has been professionally trained to use  
 *
  I understand there are no guarantees for length of time the lashes will stay permed  
 *
ACKNOWLEDGMENT (please read entire section below)
-I’m over the age of 18 and not under the influence of ANY illegal drugs or alcohol.

-  I’m not pregnant or nursing, and it has been at least 6 months since I've last nursed.

- If any unforeseen condition arises in the course of the procedure to be performed, I authorize my technician to use his or her professional judgment to decide what he/she feels is necessary under the given circumstances.

- All known allergies to pigments, adhesives and dyes have been disclosed to MT BROW BAR.

- I accept and am knowingly and voluntarily consenting to the permanence of the procedure as well as the possible known and unknown complications and consequences of said procedure(s).

 -I have been informed that the highest standards of hygiene are met for each individual client, procedure and visit.
 
- I understand that I may have to return for a repeated procedure.
 
- The result of the procedure can be affected by the following: medication, skin characteristics (dry- oily- sun-damaged thick or thin skin type)- personal pH balance of your skin, alcohol intake, smoking, and post procedure aftercare.

- To my knowledge, I do not have any physical, mental or medical impairment or disability that might affect my well-being as a direct or indirect result of my decision to have the procedure done at this time.

- I have fully and truthfully advised MT BROW BAR of any and all medication for depression or any other mood altering prescription(s)

 - I agree to follow all pre-procedure and post-procedure instructions as provided and explained to me by the technician. Failure to do so may jeopardize my chances for a successful procedure.

- I have been informed of the nature, risks, and possible complications and consequences of lash lifts and tints.

- I understand that if I have any skin treatments, injectables, laser hair removal, plastic surgery or other skin altering procedure, it may result in adverse changes to my procedure.

- I understand that the taking before and after photographs of the said procedure(s) are a condition of such procedure(s).

I have read and understand the risks listed ABOVE and they have been explained to me. I certify that the information in the above questionnaire is accurate and that it has been explained to me in detail and my questions have been answered. I accept full responsibility for any complications that may arise or result during or following the cosmetic procedure(s) to be performed at my request (Sign name below)

  To my knowledge, I do not have any mental or medical impairment or disability which might affect my well-being as a direct or indirect result of my decision to have a Lash Lift and Tint procedure done at this time. I assume full responsibility for my decision to have this procedure(s) and release ASHLEY SYKORA/MT BROW BAR from any and all liability both now and in the future.

 *
If I insist on driving, I waive all responsibility to my practitioner and I assume full responsibility that I can see to drive, perfectly.
 *
I agree to pay for any and all damages and injuries to any persons and property belonging to ASHLEY SYKORA/MT BROW BAR to who they may become liable contractually or by operation of law, caused by or resulting from my decision to have a Lash Lift and Tint procedure at this time.
 *
I understand that in the first 48 hours I am NOT to have any exposure to heat or steam, get my lashes wet, sleep on my lashes (please sleep on side or back) or rub my eyes.  I understand it may result in adverse changes to my Lash Lift and Tint. I assume full and complete responsibility.
 *
I understand the following AFTERCARE shall be advised and followed:

First 24 hours:
   Avoid getting lashes wet
   Avoid exposure to heat or steam
   Do not rub eyes
   No makeup products, oils, face creams
   Sleep on side or back

2nd Day after Procedure
   Do not rub eyes
   Avoid exposure to heat or steam
 
Ongoing Aftercare Routine:
   Do not rub eyes
   No waterproof mascara
   No oil-based products (castor oil, etc)
   Use a gentle foaming cleanser  (Cetaphil)
   Brush lashes gently to retain shape
   Use oil-free eyelash enhancing serum *
I fully understand the procedure and give permission to ASHLEY SYKORA/MT BROW BAR to perform the service of Lash Lift and Tint and all procedure(s) and steps involved.
 *

I am voluntarily receiving this procedure. I understand that there are risks associated with this procedure.  Injuries or outcomes may arise from my own or other’s actions.  I am assuming all risks of the procedure(s), whether known or unknown to me. I accept full and complete responsibility.

 *
  I understand that all negatives, together with prints or video shall become and remain the property of ASHLEY SYKORA/MT BROW BAR solely and completely. I agree to allow MTBB to utilize any/all photos taken pre/post procedure for use of social media, education and record keeping. (Full photo release). *


I hereby grant irrevocable consent to and authorize the use of any reproduction by ASHLEY SYKORA/MT BROW BAR, any and all photographs which are taken this day of me, negative or positive proof which will be hereby attached for any purposes whatsoever, without further compensation to me. *
I release from liability and waive my right, and the right of my heirs, assigns, and legal representatives to bring a claim against ASHLEY SYKORA/MT BROW BAR, its representatives, agents, or employees and its subsidiaries (“collectively “MT BROW BAR”) for any and all claims, including claims of ASHLEY SYKORA/MT BROW BAR alleged negligence, resulting in any physical injury, illness (including death) or economic loss I may suffer or which may result from my participation in the procedure(s).  
 *

I have read this document, and I am signing it freely. I understand the legal consequences of signing this document, including (a) releasing ASHLEY SYKORA/MT BROW BAR from all liability, (b) waiving my right and the right of my heirs, assigns, and legal representatives to sue ASHLEY SYKORA/MT BROW BAR, (c) and assuming all risks of participating in the procedure(s).

 *
Date *
MM
/
DD
/
YYYY
Sign Name Below *
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms