Lash Lift and Lash Tint Consent Form

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Name

Phone

Date

agree to have an eyelash perm and or Tint applied to my natural eyelashes. By signing this agreement, I consent to the procedure of an eyelash perm by Adore.

I understand there are risks associated with having an eyelash perm and 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 understand that even though Adore perms and/or Tints the lashes using the proper technique, the instruments, tapes, cleaners, eye gel pads, adhesives, and removers used may irritate my eyes.

I agree to allow pictures to be taken and shared of me.

I agree that if I experience any of these medical conditions with my lashes that I will contact Adore and consult a physician at my own expense.

I understand and consent to having my eyes closed and covered for the duration of the 45-60 minute procedure.

I understand there are no guarantees for curl tightness and RESULTS WILL VARY.

It is my responsibility to discuss desires results with my service provider and to ask any questions I may have about the lash perm before I receive the service.

I understand that there are many factors that may affect the life of the eye lash perm and tint such as; water and moisture contact, weather conditions, and activities involving exposure to high temperatures.

Because RESULTS VARY and are NOT GAURANTEED, refunds will not be issued if curl results are not desired.

I am informing Adore of the following conditions by marking with a check:

Current use of contact lenses which I agree to remove during application

Current use of anything such as oil-containing sunscreen or moisturizers around the eyes:

Current use of anything such as oil-containing sunscreen or moisturizers around the eyes: (copy)

Current use of eye drops of any kind, prescription or over-the-counter

Parent or Guardian Consent (Required for Minors):

I GIVE MY PERMISSION as parent ( ) or guardian ( ) of:

for this service. I have read and fully understand and accept this Informed Consent/Release of Liability Form and agree to accept all of the provisions and certify that the information collected is true.

Current use of eye drops of any kind, prescription or over-the-counter (copy)

Parent or Guardian Consent (Required for Minors): (copy)

I GIVE MY PERMISSION as parent ( ) or guardian ( ) of: (copy)

Current use of eye drops of any kind, prescription or over-the-counter (copy)

Client Signature (copy)

Minor? (copy)

Parent or Guardian Consent (Required for Minors): (copy)

I GIVE MY PERMISSION as parent ( ) or guardian ( ) of: (copy)

Date (copy)

Layout (copy)

Client Signature (copy)

Minor? (copy)

Parent or Guardian Consent (Required for Minors): (copy)

I GIVE MY PERMISSION as parent ( ) or guardian ( ) of: (copy)

Date (copy)

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Current use of eye drops of any kind, prescription or over-the-counter.

urrent allergies or sensitivities to instruments, fumes, tapes, cleaners, eye gel pads, adhesives, and removers that could cause my eyes to water and blink in excess.

Current use of eye drops of any kind, prescription or over-the-counter. (copy)

402 669 7094

By Appointment Only

4935 S 136th St, Omaha, NE, 68137

Lash Lift and Lash Tint Consent Form

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