Eyelash Lift/ Tint Consent Form

I agree to have an eyelash lift (perm), eyelash tint and/or eyebrow tint applied to my natural eyelashes and/or brow. By signing this agreement, I consent to the procedure of an eyelash perm or tint by my technician.  

I understand there are risks associated with having an eyelash perm and/or tint. I further understand that as part of the 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 medical conditions with my lashes that I will contact my technician and consult a physician at my own expense.  

I understand that even though my technician perms the lashes using the proper technique, the instruments, tapes, cleaners, eye gel pads, adhesives, and removers used may irritate my eyes or require a physician?s follow-up care.   

I understand and agree to the care instructions provided by my technician for the use and care of my permed and/or tinted eyelashes. I realize and accept the consequences of failure to adhere to these instructions may cause the eyelashes to not stay permed as long as told.   

I understand and consent to having my eyes closed and covered for the duration of the 45-60 minute procedure.
1. Check all that apply: Currently Use
2. Do you have any allergies the technician should be aware of? *
3. If yes, please list: *
4. Do you have a history of recurrent eye or tear duct infections? History of Sjorgen's Syndrome or dry eyes? *
5. Recent History of Chemotherapy? *
6. Any other medical conditions your technician should be aware of?
By signing below, I verify that I have read and understand the above statements and agree to them.