Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

Country

(###)

###

####

Please Check All That Apply *

Skin Disorder

Eye Infection

Watery Eyes

Bells Palsy

Allergies to Latex or Band Aides

Are you pregnant or lactating?

Inflammation of the skin

Recent eye surgery

Previous reactions to eye an eye treatement

Allergies to adhesive, glues, or bonding agents

Eye disease

Blpharitis

Allergies

Contact lenses

Are you taking HRT?

None of The Above

Have you had any of the following services? *

Check all that apply

Lash Lift Treatment

Lash Perm

Lash Tinting

Semi Permanent Mascara

Brow Tinting

None of The Above

Agreement *

I request and consent to these procedures being carried out today without undergoiong a sensitivity patch test. The sensitivity test, which if conducted, may indicate my sensitivity/ allergy to the products. I understand the contents of this form and take full responsibility for my actions, thus absolving all other parties of their responsibilites, if any, associated with the supply of the products and service(s).

I have read, understand, and agree to the statement above.

I give The Lash Lift permission to use my before + after photos