Lash Lift Consent / Liability Waiver

1. Today's Date *
2. Please tell us about yourself! *
3. What is your date of birth?
4. Referred By: *
5. If you were referred by someone you know, please tell us who! We like to give referral bonuses to our clients who refer us! If you were referred by an event you attended, please tell us which one!
6. Is this your first lash lift + tint? *
7. If you've had a lash lift or tint before, did you experience any adverse reaction to either service?
8. If yes, please describe the reaction.
9. Did you seek medical advise from a doctor or specialist as a result of this reaction?
10. If yes, what was the advice of your doctor/treatment given?
11. Do you wear contact lenses? We may ask you to remove them before your lash service. *
12. Please select any of the following that pertain to you: *
After Care
To ensure you can enjoy your Elleebana Lash Lift for 2-3 months, please follow these AFTER CARE instructions: 

NO: water, tears, heat, steam (including cooking over steaming stove-top), saunas, oils, lotions, creams, shampoos, face washes, makeup, makeup remover wipes or pads on lashes for minimum of 24 hours.

Only approved product to put on immediately after a lift that will not cause your Elleebana Lash Lift to fall is the Elleevate Mascara. 

We also advise that because the clients lashes are still malleable (shape shifting) a side sleeper or face sleeper can notice one or both eyes can raise or drop, leaving the lashes misshaped. Sleeping on the back is best. Stay away from face washes that are mainly oil as this will also cause lashes to drop prematurely. If you apply the Elleevate mascara make sure that you remove it with cold water, within the 24 hour period. 
Agreement
I understand that there are risks associated with the Lash Lift (+ tint) procedure, as with any beauty treatment.

I understand that the lashes will be curled with an advanced solution and a conditioning cream.

I understand that as part of the procedure eye irritation, pain, itching discomfort and in rare cases eye infection may occur.

I understand and agree to follow the aftercare instructions provided by my technician.

I understand failure to follow the aftercare instructions may cause an undesirable result.

I understand that in order to have a Lash Lift (+ tint), I will need to keep my eyes closed for duration up to 60 minutes during the procedure.

I also understand that I will need to be lying in a reclined position. Any medical conditions that might be aggravated by lying still for a prolonged period of time may mean that I will not be able to have the procedure performed on my eyes.

I understand that opening my eyes at any point during the Lash Lift (+tint) procedure is not recommended, and may cause an undesirable result.

I agree to keep my eyes closed throughout the procedure unless instructed to open them by my technician.

This agreement will remain in effect for this procedure and all future Lash Lift (+ tint) procedures conducted by my technician or any other technician conducting business at the salon/spa listed below.

I understand that this agreement is binding and that I have read and fully understand all information above. I represent that I am over the age of 18 years. If below 18 years of age a parent or guardian must also sign this form.

I release my technician or salon/spa Butterfly Kiss Lash Studio from all liability associated with this procedure.

There are no guarantees for how long the lash lift will last, on average it lasts between 6-8 weeks. Our company or salon is not responsible for any technician errors.

I understand that I have been advised to follow the aftercare protocol from my technician so as to avoid any discomfort or adverse side effects after the procedure has been completed.

RESULTS MAY VARY. Our eyelashes are each unique and require slightly different processing times based on coarseness and density. If desired results are not achieved, processing times will be adjusted for future lifts. Please understand your lash health is our utmost priority, and we take careful consideration to not over-process your lashes. 

I request and consent to these procedures being carried out today without undergoing 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 responsibilities, if any, associated with the supply of the products and services(s).
Authorization For Use or Disclosure of Client Photographic and/or Video Images
AUTHORIZATION: I authorize the use and disclosure of my name, photographic/video images, and/or testimonial for marketing purposes by the practice/salon listed below. I understand that information disclosed pursuant to this authorization may be subject to redisclosure and may no longer be protected by HIPAA privacy regulations.
PURPOSE: The photographic/video images, and/or testimonial will be used for: Social Media and/or Advertising
REVOCABILITY: I understand that I may revoke this authorization at any time, but such revocation must be in writing and received by the practice/salon via registered mail. Revocation a?ects disclosure moving forward and is not retroactive. This authorization expires 99 years from date signed.
NO TREATMENT CONDITIONS: I understand that the practice/salon cannot condition treatment on whether or not I sign this authorization.
Please ask your lash artist for a copy of this if you desire one. 
13. May we use your photos/videos per the above paragraph? *
Please sign here *