Lift & Tint Consent Form

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Consent and Waiver for lift & tint services with dhesthetics

Email *

Client Information

General information required for liability purposes.

First & Last Name *

Phone Number *

Address *

Date of Birth (Used for special promotions😉) *

YYYY

Are you over the age of 18? *

Yes

No (parental consent needed if under 18)

Do you consent to receiving emails from dhesthetics? *

Yes

No, do not subscribe

How did you find out about dhesthetics? *

Instagram/Facebook

Google Search

Referred by a friend

Other:

General Information & Consultation

Have you had a lift & tint before? *

Yes

Other:

If so, where did you get it done? What did you like/not like about it? (This is simply used to help me understand your expectations & needs) *

When is the last time you had a lash lift & tint? *

Service Consent & Waiver

I understand that the lift & tint solution will be applied to the lashes for a suitable, yet effective length of time thereby preserving the health, growth and natural look of the clients natural eyelashes. *

I understand

I understand that in order to receive a lift & tint I will need to keep my eyes closed for duration of 30-45 minutes during the procedure. I also understand that I will need to be lying in a reclined position. Any medical conditions that may be aggravated by lying still for a prolonged period of time, means that I will not be able to have the procedure performed on my eyes. *

I understand

I understand and agree to follow the aftercare instructions provided by Danielle (dhesthetics). Failure to follow the aftercare instructions may cause the lift to relax prematurely or cause damage to my lashes. *

I understand

I release Danielle (dhesthetics) from all liability associated with this procedure. There are no guarantees for the length of time a lift & tint will last. I understand that I have been advised to follow the aftercare protocol from Danielle (dhesthetics) so as to avoid any discomfort or adverse side effects after the procedure has been completed. *

I understand

I agree that if any pictures are taken of my lashes/face that they may be posted to dhesthetics Instagram/Facebook or website page & that I will be tagged where/when possible. (Suitable editing will be done prior to posting) *

I consent

I do not consent

I verify that I have read and understand the above statements and fully agree to them all. *

Yes

Policy Consent

I understand that any deposit provided to dhesthetics for services is NON-REFUNDABLE. The deposit may be transferred to a new appointment time if reasonable notice is given for cancellation. *

I understand

I understand that if I no-show an appointment or cancel with less than 48 hours notice, 50% of my appointment total is due prior to re-booking. *

I understand

I understand that I must provide 48+ hours notice when rescheduling a lift & tint appointment. I understand that if I reschedule my appointment with less than 48 hours notice I will be charged a rescheduling fee of $20. *

I understand

I understand that any service rendered, completed and paid for in full by dhesthetics is NON-REFUNDABLE. *

I understand

I verify that I have read and understand the above policies and that they will apply to ALL future appointments and I agree. *

Yes

Medical Form

Do you have any allergies? PLEASE LIST ALL ALLERGIES *

Yes

Other:

Have you had chemotherapy or any type of optical surgeries within the past 6 months? *

Yes

Are you on thyroid medication? *

Yes

Do you have extremely oily skin or hair? (hyperseborrhea) *

Yes

Do you agree to remove contact lenses before your appointment? *

Yes

Do you agree to discontinue use of lash growth serums 24 hours before your scheduled appointment? *

Yes

Client Consent

The information I have given on this form is correct. I have not misrepresented myself nor have I withheld any medical information, surgical state or condition. *

I affirm

Cannot affirm

This agreement will remain in effect for this procedure and all future lash lift procedures conducted by Danielle (dhesthetics). I understand that this agreement is binding and that I have read and fully understand all information 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 a physical form in person prior to treatment. *

I affirm

Cannot affirm

Please type your full name below to be used as your official signature for this document * *

Submit

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