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Eyelash Lift/Tint & Brow Tint Consent Form

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

I understand there are risks associated with having an eyelash perm and/or eyelash or brow tint. I further understand that as part of the procedure, eye/skin irritation, eye/skin pain, eye/skin itching, eye/skin discomfort, and in rare cases eye/skin infection or eye blurriness could occur. I agree that if I experience any of these medical conditions with my lashes or skin that I will contact my technician and consult a physician at my own expense.

I understand that even though my technician perms and/or tints the lashes and or brows; 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 follow the care instructions for the use and care of my permed and/or tinted eyelashes or brows. 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 or tint to last as long as told. I understand and consent to having my eyes closed and covered for the duration of the 30 minute procedure.

I understand that tinting lashes or brows has some inherant risk of irritation to the orbital eye and skin.  This could result in burning, stinging or other form of reaction.  I also understand that there might be some residual tint on the skin that will wear off in a few days.  I will consult my technician and/or read the ingredients of products to see if there is an allergy.

I am informing my technician of the following conditions:

  • 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 eyedrops of any kind, prescription or over-the-counter.
  • Current 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.
  • History of recurrent eye or tear duct infections.
  • History of dry eyes or Sjorgen’s Syndrome.
  • Recent history of Chemotherapy.
  • Other medical conditions which would prohibit or compromise the process and retention of this eyelash perm.
  • Skin sensitivity or allergy conditions.

I agree to the following eyelash perm post-op and maintenance instructions: No water can come in contact with the eye area for 24 hours after the application. This agreement will remain in effect for this procedure and all future procedures conducted by my technician.

I read English and understand that this consent agreement is legal and binding. I have read and fully understand all information in this agreement.

I am over 18 years of age and consent to the agreement and to treatment.

I release The Naked Peach Waxing Boutique and my technician from all liability associated with this procedure. There are no guarantees for length of time the lashes will stay permed. I understand that there are many factors that may affect the life of the eyelash lift such as water and moisture contact, weather conditions, and activities involving exposure to high temperatures.

By signing below, I verify that I have read and understand the above statements and agree to them.

 

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
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Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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