LASH LIFT & TINT CONSENT FORM

First Name *

Last Name *

Phone *

Email *

Date of birth

Age

Address

City

State

MEDICAL HISTORY

Lash Lift & Tint Medical History: Select any conditions listed below that apply to you:

Allergic reaction to hair color/eyelash tint

History of recurrent eye or tear duct infections

Dry eyes or Sjorgen’s Syndrome

Seasonal allergies

Eye illness or injury

Blepharitis

Drugs that can cause temporary hair loss

Have you had an eyelash lift before?

Yes

Do you have any additional allergies such as to metals, soaps, cosmetics or alcohol?

Do you have any other medical or skin conditions that affect the outcome of your procedure?

Lash Lift & Tint: if you have any medical condition above

I confirm that I have a medical condition, and I have consulted with a healthcare professional/doctor regarding this condition. My healthcare professional/doctor has advised me that lash lift and tint is safe for me to undergo, given my medical condition.

PLEASE READ AND CHECK THE BOXES WHEN YOU ARE CERTAIN YOU UNDERSTAND THE IMPLICATIONS OF SIGNING

In consideration of receiving eyelash lift and tint from Van Nguyen, Mes Amies Brows (together with its employees, apprentices, and agents:

Lash Lift & Tint: check all the boxes below to confirm:

I understand that there are risks associated with having an eyelash lift.

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.

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.

I hereby grant permission for pictures and videos of my procedure to be taken. I understand and agree that these images may be used for record-keeping purposes and/or promotional and advertising materials.

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.

I understand that an eyelash lift will lift my natural eyelashes. Depending on my natural eyelash length and strength, results may vary.

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.

I understand and consent to having my eyes closed and covered for the entire duration of the procedure

AFTERCARE INSTRUCTIONS

The following written instructions were communicated to the client:

1. Keep Lashes Dry: Avoid getting your lashes wet for the first 24 hours post-treatment to ensure the lift sets properly.

2. Avoid Steam and Heat: For the first 48 hours, avoid steam rooms, saunas, and hot showers to protect the tint and lift.

3. Gentle Cleansing: Use a gentle, oil-free cleanser around your eyes. Avoid rubbing or pulling at your lashes.

4. No Eye Makeup for 24 Hours: Avoid mascara and any eye makeup for the first day to prevent any interference with the lift and tint.

5. Sleep Position: Try to sleep on your back the first night to avoid bending the lashes.

6. Avoid Lash Curlers: Your lashes are already lifted! Using a lash curler can weaken or damage them.

7. Brush Gently: If needed, you can gently brush your lashes with a clean spoolie brush to keep them neat.

8. Avoid Oil-Based Products: Oils can break down the tint and lift. Use oil-free products around your eyes.

9. Regular Maintenance: Schedule touch-ups every 6-8 weeks to maintain the lift and tint.

10. Contact for Concerns: Should you experience any irritation or have concerns, please contact us immediately.

Artist Name

Date Signed *

Signature *

Clear

By providing my phone number, I agree to receive text messages from the business regarding aftercare instructions, appointment reminders, and promotions.