LASH LIFT CONSENT FORM

Name *

First Name

Last Name

Phone *

(###)

###

####

Birthdate *

MM

DD

YYYY

PREVIOUS DISCOMFORT, STINGING OR ADVERSE REACTIONS: Please check any that apply.

Skin disorders

Inflammation of the skin

Eye disease

Eye infections

Recent eye surgery

Blephartitis

Watery eyes

Hay fever

Allergies

Bell's Palsy

Previous reactions to eye treatments

Contact Lenses

Allergies to latex/band aids

Allergies to glue/bonding agents/adhesives

Alleriges to acetone

Are you pregnant/lactating?

Are you on a contraceptive pill?

Are you taking HRT?

Have you had lash or brow tinting, lash lifting, lash perming, eyelash extension or semi-permanent mascara applied previously?

Yes

NO

Signature *

First Name

Last Name