General Lash Lift Tint Consent Form

Street address

Have you ever had any of the following or adverse reactions to any listed below

Skin DisordersInflammation of SkinEye DiseaseEye InfectionsEye SurgeryBlephartitisWatery EyesHay FeverAllergiesBell’s PalsyContact LensesAllergies to LatexAllergies to AcetonePregnant/LactatingTaking HRTUse of ContraceptionAllergies to glues, adhesives, bonding agentsPrevious reactions to eye treatments

If yes to any above, please explain

Current Medications/Supplements

Previously received lash/brow tinting, lash perming, lash extensions or semi-permanent mascara?
YesNo

If yes
TintingLash Perm/LiftLash ExtensionsSemi-Permanent Mascara

Did you experience any reaction to any of these treatments?
YesNo

If yes, to which service, please explain

Did you seek medical advice from a doctor or specialist as a result of the reaction and if so, what was the advice and/or treatment?

I request & consent to these procedures being carried out today without undergoing a sensitivity patch. The sensitivity test,which if conducted, may indicate my sensitivity or allergy to the products, I agree to contact my treatment provider in the first onset of any reactions that may occur. I understand the contents of this form and have been truthful with all my answers. I take full responsibility for my actions, thus absolving all other parties of their responsibilities, if any, associated with the supply of the products and services.