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YUMI Lash Lift and Tint Intake and Consent Form

Bella Lash Brow

YUMI Lash Lift | BROW x LASH TINTING INTAKE & CONSENT FORM

I understand that there is no patch test being carried out 24hrs prior to treatment. I also understand the risks associated with having a keratin lash lift treatment and/or brow/lash tinting and also understand the importance of following the aftercare and maintenance guide (given after treatment) which will determine how long the lashes/brows last and reduce the chance of any risks.

I Agree

Today's Date: August 26, 2019

First * Name

First Name*

Last Name*

Phone*
First * Date of Birth*
First * Information

Job role:
How did you FIRST hear about Bella Lash Brow?*
Have you had a lash lift or a tint before?*
No
Yes

If yes, where have you had a lash lift and/or a tint? (most recent place if more than one)?
Within the last 60 days, have you had any of the following types of treatments?
Individual Lash Extensions
Lash tint
Brow tint
Lash Lift
Do you have or are you being treated for any eye illness or injury?*
No
Yes
Please check if any of the following apply to you:
Laser Eye Surgery
Epilepsy
Dry Eye syndrome
Conjunctivitis
Psoriasis
Trichotillomania
Alopecia
Cataract
Diabetic Retinopathy
Glaucoma
Herpes Simplex
Currently pregnant

Any other known medical conditions which may affect the suitability for an eyelash treatment?
First * Signature*
Second * Name

First Name*

Last Name*
Second * Date of Birth*
Second * Information

Job role:
How did you FIRST hear about Bella Lash Brow?*
Have you had a lash lift or a tint before?*
No
Yes

If yes, where have you had a lash lift and/or a tint? (most recent place if more than one)?
Within the last 60 days, have you had any of the following types of treatments?
Individual Lash Extensions
Lash tint
Brow tint
Lash Lift
Do you have or are you being treated for any eye illness or injury?*
No
Yes
Please check if any of the following apply to you:
Laser Eye Surgery
Epilepsy
Dry Eye syndrome
Conjunctivitis
Psoriasis
Trichotillomania
Alopecia
Cataract
Diabetic Retinopathy
Glaucoma
Herpes Simplex
Currently pregnant

Any other known medical conditions which may affect the suitability for an eyelash treatment?
Third * Name

First Name*

Last Name*
Third * Date of Birth*
Third * Information

Job role:
How did you FIRST hear about Bella Lash Brow?*
Have you had a lash lift or a tint before?*
No
Yes

If yes, where have you had a lash lift and/or a tint? (most recent place if more than one)?
Within the last 60 days, have you had any of the following types of treatments?
Individual Lash Extensions
Lash tint
Brow tint
Lash Lift
Do you have or are you being treated for any eye illness or injury?*
No
Yes
Please check if any of the following apply to you:
Laser Eye Surgery
Epilepsy
Dry Eye syndrome
Conjunctivitis
Psoriasis
Trichotillomania
Alopecia
Cataract
Diabetic Retinopathy
Glaucoma
Herpes Simplex
Currently pregnant

Any other known medical conditions which may affect the suitability for an eyelash treatment?
Fourth * Name

First Name*

Last Name*
Fourth * Date of Birth*
Fourth * Information

Job role:
How did you FIRST hear about Bella Lash Brow?*
Have you had a lash lift or a tint before?*
No
Yes

If yes, where have you had a lash lift and/or a tint? (most recent place if more than one)?
Within the last 60 days, have you had any of the following types of treatments?
Individual Lash Extensions
Lash tint
Brow tint
Lash Lift
Do you have or are you being treated for any eye illness or injury?*
No
Yes
Please check if any of the following apply to you:
Laser Eye Surgery
Epilepsy
Dry Eye syndrome
Conjunctivitis
Psoriasis
Trichotillomania
Alopecia
Cataract
Diabetic Retinopathy
Glaucoma
Herpes Simplex
Currently pregnant

Any other known medical conditions which may affect the suitability for an eyelash treatment?
Fifth * Name

First Name*

Last Name*
Fifth * Date of Birth*
Fifth * Information

Job role:
How did you FIRST hear about Bella Lash Brow?*
Have you had a lash lift or a tint before?*
No
Yes

If yes, where have you had a lash lift and/or a tint? (most recent place if more than one)?
Within the last 60 days, have you had any of the following types of treatments?
Individual Lash Extensions
Lash tint
Brow tint
Lash Lift
Do you have or are you being treated for any eye illness or injury?*
No
Yes
Please check if any of the following apply to you:
Laser Eye Surgery
Epilepsy
Dry Eye syndrome
Conjunctivitis
Psoriasis
Trichotillomania
Alopecia
Cataract
Diabetic Retinopathy
Glaucoma
Herpes Simplex
Currently pregnant

Any other known medical conditions which may affect the suitability for an eyelash treatment?
Sixth * Name

First Name*

Last Name*
Sixth * Date of Birth*
Sixth * Information

Job role:
How did you FIRST hear about Bella Lash Brow?*
Have you had a lash lift or a tint before?*
No
Yes

If yes, where have you had a lash lift and/or a tint? (most recent place if more than one)?
Within the last 60 days, have you had any of the following types of treatments?
Individual Lash Extensions
Lash tint
Brow tint
Lash Lift
Do you have or are you being treated for any eye illness or injury?*
No
Yes
Please check if any of the following apply to you:
Laser Eye Surgery
Epilepsy
Dry Eye syndrome
Conjunctivitis
Psoriasis
Trichotillomania
Alopecia
Cataract
Diabetic Retinopathy
Glaucoma
Herpes Simplex
Currently pregnant

Any other known medical conditions which may affect the suitability for an eyelash treatment?
Seventh * Name

First Name*

Last Name*
Seventh * Date of Birth*
Seventh * Information

Job role:
How did you FIRST hear about Bella Lash Brow?*
Have you had a lash lift or a tint before?*
No
Yes

If yes, where have you had a lash lift and/or a tint? (most recent place if more than one)?
Within the last 60 days, have you had any of the following types of treatments?
Individual Lash Extensions
Lash tint
Brow tint
Lash Lift
Do you have or are you being treated for any eye illness or injury?*
No
Yes
Please check if any of the following apply to you:
Laser Eye Surgery
Epilepsy
Dry Eye syndrome
Conjunctivitis
Psoriasis
Trichotillomania
Alopecia
Cataract
Diabetic Retinopathy
Glaucoma
Herpes Simplex
Currently pregnant

Any other known medical conditions which may affect the suitability for an eyelash treatment?
Eighth * Name

First Name*

Last Name*
Eighth * Date of Birth*
Eighth * Information

Job role:
How did you FIRST hear about Bella Lash Brow?*
Have you had a lash lift or a tint before?*
No
Yes

If yes, where have you had a lash lift and/or a tint? (most recent place if more than one)?
Within the last 60 days, have you had any of the following types of treatments?
Individual Lash Extensions
Lash tint
Brow tint
Lash Lift
Do you have or are you being treated for any eye illness or injury?*
No
Yes
Please check if any of the following apply to you:
Laser Eye Surgery
Epilepsy
Dry Eye syndrome
Conjunctivitis
Psoriasis
Trichotillomania
Alopecia
Cataract
Diabetic Retinopathy
Glaucoma
Herpes Simplex
Currently pregnant

Any other known medical conditions which may affect the suitability for an eyelash treatment?
Ninth * Name

First Name*

Last Name*
Ninth * Date of Birth*
Ninth * Information

Job role:
How did you FIRST hear about Bella Lash Brow?*
Have you had a lash lift or a tint before?*
No
Yes

If yes, where have you had a lash lift and/or a tint? (most recent place if more than one)?
Within the last 60 days, have you had any of the following types of treatments?
Individual Lash Extensions
Lash tint
Brow tint
Lash Lift
Do you have or are you being treated for any eye illness or injury?*
No
Yes
Please check if any of the following apply to you:
Laser Eye Surgery
Epilepsy
Dry Eye syndrome
Conjunctivitis
Psoriasis
Trichotillomania
Alopecia
Cataract
Diabetic Retinopathy
Glaucoma
Herpes Simplex
Currently pregnant

Any other known medical conditions which may affect the suitability for an eyelash treatment?
Tenth * Name

First Name*

Last Name*
Tenth * Date of Birth*
Tenth * Information

Job role:
How did you FIRST hear about Bella Lash Brow?*
Have you had a lash lift or a tint before?*
No
Yes

If yes, where have you had a lash lift and/or a tint? (most recent place if more than one)?
Within the last 60 days, have you had any of the following types of treatments?
Individual Lash Extensions
Lash tint
Brow tint
Lash Lift
Do you have or are you being treated for any eye illness or injury?*
No
Yes
Please check if any of the following apply to you:
Laser Eye Surgery
Epilepsy
Dry Eye syndrome
Conjunctivitis
Psoriasis
Trichotillomania
Alopecia
Cataract
Diabetic Retinopathy
Glaucoma
Herpes Simplex
Currently pregnant

Any other known medical conditions which may affect the suitability for an eyelash treatment?
* Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
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*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Job role:
How did you FIRST hear about Bella Lash Brow?*
Have you had a lash lift or a tint before?*
No
Yes

If yes, where have you had a lash lift and/or a tint? (most recent place if more than one)?
Within the last 60 days, have you had any of the following types of treatments?
Individual Lash Extensions
Lash tint
Brow tint
Lash Lift
Do you have or are you being treated for any eye illness or injury?*
No
Yes
Please check if any of the following apply to you:
Laser Eye Surgery
Epilepsy
Dry Eye syndrome
Conjunctivitis
Psoriasis
Trichotillomania
Alopecia
Cataract
Diabetic Retinopathy
Glaucoma
Herpes Simplex
Currently pregnant

Any other known medical conditions which may affect the suitability for an eyelash treatment?
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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