Lash Lift Consent
Sign in to Google to save your progress. Learn more
Name *
Address *
Cell *
Email *
Have you had an eyelash lift in the past? *
If yes, how long ago?
Have you ever used hair color/eyelash tint? *
Have you ever had an allergic reaction to hair color/eyelash tint? *
Do you wear contact lenses? *
Are you currently using eye drops of any kind, prescription or over-the-counter? *
Do you have a history of recurrent eye or tear duct infections? *
Do you have a history of dry eyes or Sjorgen’s Syndrome? *
List any allergies you have:
List any illnesses, medical conditions, or medical treatments you have recently received that would prohibit or compromise the process and retention of this eyelash lift: *
Although every precaution will be taken to ensure your safety and well-being before, during, and after your eyelash lift, please be aware of the following information and possible risks. Please initial:
__ I understand that there are risks associated with having an eyelash lift.
 *
Although every precaution will be taken to ensure your safety and well-being before, during, and after your eyelash lift, please be aware of the following information and possible risks. Please initial:
__ I understand that as part of the eyelash lift procedure, eye irritation, eye pain, eye itching, discomfort, and in
rare cases, eye infection or blurriness could occur.
 *
Although every precaution will be taken to ensure your safety and well-being before, during, and after your eyelash lift, please be aware of the following information and possible risks. Please initial:
__ I agree that if I experience any of these conditions with my eyelashes or eyes, that I will contact my
technician; if I choose to consult a physician, it will be at my own expense.
 *
Although every precaution will be taken to ensure your safety and well-being before, during, and after your eyelash lift, please be aware of the following information and possible risks. Please initial:
__ I understand that the instruments, tapes, cleaners, eye gel pads, adhesives, and/or removers may irritate my
eyes or require a physician’s follow-up care, even though my technician utilized correct techniques and followed
proper safety protocols.
 *
Although every precaution will be taken to ensure your safety and well-being before, during, and after your eyelash lift, please be aware of the following information and possible risks. Please initial:
__ I understand that an eyelash lift will lift my natural eyelashes. Depending on my natural eyelash length and
strength, results may vary.
 *
Although every precaution will be taken to ensure your safety and well-being before, during, and after your eyelash lift, please be aware of the following information and possible risks. Please initial:
__ I understand and agree to the care instructions provided by my technician for the use and care of my
eyelashes after the eyelash lift. I realize and accept that the consequences of failure to adhere to these
instructions may cause the eyelashes to not stay as lifted as long as originally told.
 *
Although every precaution will be taken to ensure your safety and well-being before, during, and after your eyelash lift, please be aware of the following information and possible risks. Please initial:
__ I understand and consent to having my eyes closed and covered for the entire duration of the procedure.
 *
I agree to the following eyelash lift care and maintenance instructions:

No water can come in contact with the eye area for 24 hours after the applications.
This agreement will remain in effect for this procedure and all future procedures conducted by my technician.
I have read the above information. If I have any concerns, I will address these with my esthetician/technician. I give
permission to my esthetician/technician to perform the eyelash lifting procedure we have discussed and will hold
him/her and his/her staff harmless from any liability that may result from this treatment. I have accurately answered
the questions above, including all known allergies, prescription drugs, or products I am currently ingesting or using
topically. I understand my esthetician/technician will take every precaution to minimize or eliminate negative reactions
as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult
the esthetician/technician immediately. I agree that this constitutes full disclosure, and that it supersedes any previous
verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had
sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks.
I do not hold the esthetician/technician, whose signature appears below, responsible for any of my conditions that were
present, but not disclosed at the time of this procedure that may be affected by the treatment performed today.
Signature:
 *
Esthetician tech and Date *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of shellysadvancedskincare.com.

Does this form look suspicious? Report

Google Forms