Lash Lift and Tint form
Lash Lift and tinting consultation form
Name *
Email *
Address *
Phone number
Have you or anyone you have been in contact with, recently been sick or had any flu like symptoms in the last 2 weeks? *
Have you or someone you have been in contact with Traveled overseas in the last 2 weeks? *
Have you been in contact with anyone tested for Covid-19 in the last 14 days? *
I have not used a scrub, Retin-A, Retinol OTC, take home micro-dermabrasion, glycolic peels, other peels, exfoliated or tanned in the last 72 hours.
Clear selection
I have been off of Accutane for at least twelve (12) months.
Clear selection
Have you ever had an allergic reaction to hair colour?
Clear selection
Do you wear contacts?
Clear selection
Please list any illnesses or conditions you are being treated by a physician for
Please list any medications you are taking, including over-the-counter herbs, vitamins and supplements
List any allergies you have
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 physician’s follow-up care. *
Required
I understand and agree to the care instructions provided by my technician for the use and care of my permed and/or tinted eyelashes. No water/steam can come in contact with the eye area for 24 hours after the application. I realize and accept the consequences of failure to adhere to these 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 45-60 minute procedure.I understand that there are many factors that may affect the life of the eyelash lift such as water and moisture contact, weather conditions, and activities involving exposure to high temperatures. *
Required
 I understand Kirby Hair and Beauty Have a 24 hour cancellation policy. If I cancel/reschedule my appointment after the 12 hours I will be required to pay cancellation Fee of 50% of the treatment cost. No shows or cancellations 1-2 hours before appointment will be required to pay 100% of the treatment cost. This must be paid before any other bookings will be accepted. *
Required
I understand that Lash lifts, henna or tinting lashes or brows has some inherent risk of irritation to the orbital eye area, including the eye itself, and could result in stinging or burning, blurry vision and potentially blindness should the tint enter into the eye. I understand that if the Henna, tinting agent, developer, or mixture of both accidentally comes into contact with my eye, my eye will be flushed with water and medical attention may be required. I understand that some irritation, itching or burning may occur to the skin which comes in contact with the products.  I understand that there may be some residual dark staining left on the skin following the tinting process of either my lashes, brows or both. This will fade and go away within a short time. I understand that, while every attempt will be made to provide me with my chosen colour, everyone’s hair absorbs colour differently and my final results may not be the colour I initially wanted. I understand that over the course of several weeks, the tint will gradually lighten and fade. Re-tinting or Henna will be required to keep the new colour fresh. Most clients need to re-colour every 3-4 weeks. Lash lifts last upto 6-8 weeks. *
Required
I have read the above information.  I give permission to my therapist to perform the procedure we have discussed, and will hold her 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 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 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, , responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today. *
Required
I give permission for photos to be taken and used for salon purposes only *
Date
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms