Brow Lash Treatment Agreement

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Email *

Record my email address with my response

Name

Phone Number :

Emergency Contact: (name and phone)

Have you ever had extensions, tint, brow lamination, or lash lift before

yes

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Have you ever had a negative reaction to extensions, tint, lamination, or lifting solution(s) in the past? If yes please describe:

Please check any that may apply to you:

Eye surgery

Eye illness or injury

Dry eyes

Eye infection

Permanent eye make-up

Blepharoplasty

Blepharitis

Allergies to adhesives found in band aid's or medical tape

Allergies to preservatives in saline solutions

Hormonal imbalance

Pregnancy or recent childbirth

Are you using Retin-A, Benzoyl Peroxide, or any other prescription skin products within the last 3 months?

Yes

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Do you have any allergies or sensitivities?

Yes

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Have you ever experienced a reaction to any of the following: cosmetics, medicine, iodine (shellfish), latex, pollen, food/fruit, animals, fragrance, alpha hydroxy acids, sunscreens? Please include reactions here with answer:

Do you take any medications? Please list if any (Accutane, antibiotics, birth control, blood thinners etc)

I agree to have lash extensions, tint, brow lamination, and/ or lash lifting service

I understand that extensions, tinting, laminating, and/ or lifting services have some inherent risk of irritation to the skin and/ or eye area. Such as: stinging, burning, blurry vision, eye infection, etc. I agree that if I experience any of these medical conditions, I will contact my technician and consult a phsycian at my own expense.

yes

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I understand that there are no guarantees for length of time that my results will last

yes

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I release my technician and EE from all liability associated with this procedure

yes

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I understand that there are many factors that may affect the life of extensions, tint, lift, or lamination *such as water/ moisture contact, weather conditions, and activities involving exposure to high temperature

Yes

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I understand that if I need to cancel or reschedule my appointment for any reason, I will give at least 24hours notice. If I am unable to give 24hours notice, I understand that I will be charged 50% the price of my service appointment via invoice and I agree to remit payment for my missed appointment.

yes

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I agree that the information I have provided is correct to the best of my knowledge

yes

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