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Eyelash Lift Consent Form


INFORMED CONSENT FORM

Although every precaution will be taken to ensure your safety and well-being before, during, and after your treatment/procedure, please be aware of the following information and possible risks and indicate that you fully understand what to expect. Please initial:

I hereby consent to and authorize the technician/esthetician to perform the following treatment/procedure: Eyelash Lift 


I voluntarily agree to undergo this treatment/procedure after the nature and purpose of this treatment/procedure has been explained to me, along with the risks and hazards involved. 


Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications. 


I understand that it is imperative to my health and safety that I disclose all of the information requested in the Client Consultation/Health History form. I have cited all conditions and circumstances regarding my health history, allergies, and medications, supplements, or prescriptions being taken (orally and/or topically), and any past reactions to products or medications. 


I understand that no specific guarantees of the results can or have been made and that there is the possibility I may require additional treatments/procedures to obtain the expected results at an additional cost. 


I have read and understand all pre-treatment, post-treatment, and home care instructions. I understand the importance of following all instructions given to me. In the event that I have additional questions or concerns regarding my treatment or post-treatment care, I will consult the technician/esthetician immediately. I understand that if I choose to consult a physician, I do so at my own expense. 


I consent to “before-and-after” photographs for the purpose of documentation, potential advertising, and promotional purposes. 


I understand that if I have any concerns, I will address these with my technician/esthetician. I give permission to my technician/esthetician to perform the above treatment/procedure we have discussed and will hold him/her/them and his/her/their staff harmless and nameless from any liability that may result from this treatment/procedure. I understand my technician/esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read and fully understand the above paragraphs and that I have been provided sufficient opportunity for discussion and to have any questions answered. I understand the procedure and accept the risks. I do not hold the technician/esthetician, whose signature appears below, responsible for any of my conditions that were present but not disclosed at the time of this procedure that may be affected by the treatment performed today. 

Client Signature:

Date: August 1, 2026

Although every precaution will be taken to ensure your safety and well-being before, during, and after your eyelash lift, please be aware of the following information and possible risks. Please initial:

I understand that there are risks associated with having an eyelash lift.



I understand that as part of the eyelash lift 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 conditions with my eyelashes or eyes, that I will contact my technician; if I choose to consult a physician, it will be at my own expense. 



I understand that the instruments, tapes, cleaners, eye gel pads, adhesives, and/or removers may irritate my eyes or require a physician’s follow-up care, even though my technician utilized correct techniques and followed proper safety protocols. 



I understand that an eyelash lift will lift my natural eyelashes. Depending on my natural eyelash length and strength, results may vary. 



I understand and agree to the care instructions provided by my technician for the use and care of my eyelashes after the eyelash lift. I realize and accept that the consequences of failure to adhere to these instructions may cause the eyelashes to not stay as lifted as long as originally told. 



I understand and consent to having my eyes closed and covered for the entire duration of the procedure. 


 

I agree to the following eyelash lift care and maintenance instructions:

No water can come in contact with the eye area for 24 hours after the applications.

This agreement will remain in effect for this procedure and all future procedures conducted by my technician.

I have read the above information. If I have any concerns, I will address these with my esthetician/technician. I give permission to my esthetician/technician to perform the eyelash lifting procedure we have discussed and will hold him/her and his/her staff harmless from any liability that may result from this treatment. I have accurately answered the questions above, including all known allergies, prescription drugs, or products I am currently ingesting or using topically. I understand my esthetician/technician will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult the esthetician/technician immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the esthetician/technician, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this procedure that may be affected by the treatment performed today.

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

Client Signature:

Date: August 1, 2026


POLICY CONSENT

Rescheduling & Cancellations

You are responsible for rescheduling or canceling your appointment via the booking app link sent to you by text. If you are experiencing technical issues, please text Jacky at 719-297-1447.

No charges for rescheduling if done 48 hours prior to your appointment time. 


Children Policy

To fully enjoy your experience, please leave children at home unless they are being serviced. Enjoy your self-care! 


Consent Forms

After your booking is confirmed, please visit the main page of my website and click the menu bar (top right-hand corner). Select the drop-down menu, proceed to select the consent form for your treatment. Forms must be completed at least 6-8 hours prior to your treatment time. 


Arrival Instructions

Upon arrival, find Jacky’s doorbell by the reception desk. Please have a seat and wait for your name to be called. You are welcome to use the restrooms within the facility. 


Conduct Policy

Disrespectful behavior will not be tolerated. You may be dropped as a future client if Jacky feels uncomfortable or unsafe. 


Tardiness

Appointments are subject to rescheduling and additional fees if you are more than 10 minutes late. 


Cancellation Fees

  • Late cancellation (less than 48 hours): 50% of service total
  • Same-day rescheduling/cancellation: 50% of service total
  • No-show/no-call: 100% of service total

No-shows or no-calls may result in being dropped as a future client. 


Refunds & Satisfaction Policy

Please note that no refunds will be issued for services rendered. However, your satisfaction is very important to me. If you are dissatisfied with your service, please contact me directly as soon as possible. I will work with you to address your concerns and ensure you are comfortable with your results. I am committed to providing an excellent experience and will make every effort to resolve any issues.


Retail Item Policy

All retail sales are final and non-refundable. However, if you are not completely satisfied with your purchase, I am happy to offer an even exchange for another product of equal value. Please contact Jacky within 7 days of purchase to initiate the exchange. Items must be unused, unopened, and in original condition to qualify for an exchange. 



Beauty Realm LLC
(719) 297-1447

First Client's Name
First Name*
Middle Name
Last Name*
Phone*
First Client's Date of Birth*
Date of Birth
Information
Have you had an eyelash lift in the past? *
No
Yes
Have you ever used hair color/eyelash tint?*
No
Yes
Have you ever had an allergic reaction to hair color/eyelash tint? *
No
Yes
Do you wear contact lenses? *
No
Yes
Are you currently using eye drops of any kind, prescription or over-the-counter?*
No
Yes
Do you have a history of recurrent eye or tear duct infections?*
No
Yes
Do you have a history of dry eyes or Sjorgen’s Syndrome?*
No
Yes

List any allergies you have:

List any illnesses, medical conditions, or medical treatments you have recently received that would prohibit or compromise the process and retention of this eyelash lift:
First Client's Signature*
Second Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Information
Have you had an eyelash lift in the past? *
No
Yes
Have you ever used hair color/eyelash tint?*
No
Yes
Have you ever had an allergic reaction to hair color/eyelash tint? *
No
Yes
Do you wear contact lenses? *
No
Yes
Are you currently using eye drops of any kind, prescription or over-the-counter?*
No
Yes
Do you have a history of recurrent eye or tear duct infections?*
No
Yes
Do you have a history of dry eyes or Sjorgen’s Syndrome?*
No
Yes

List any allergies you have:

List any illnesses, medical conditions, or medical treatments you have recently received that would prohibit or compromise the process and retention of this eyelash lift:
Third Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Information
Have you had an eyelash lift in the past? *
No
Yes
Have you ever used hair color/eyelash tint?*
No
Yes
Have you ever had an allergic reaction to hair color/eyelash tint? *
No
Yes
Do you wear contact lenses? *
No
Yes
Are you currently using eye drops of any kind, prescription or over-the-counter?*
No
Yes
Do you have a history of recurrent eye or tear duct infections?*
No
Yes
Do you have a history of dry eyes or Sjorgen’s Syndrome?*
No
Yes

List any allergies you have:

List any illnesses, medical conditions, or medical treatments you have recently received that would prohibit or compromise the process and retention of this eyelash lift:
Fourth Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Information
Have you had an eyelash lift in the past? *
No
Yes
Have you ever used hair color/eyelash tint?*
No
Yes
Have you ever had an allergic reaction to hair color/eyelash tint? *
No
Yes
Do you wear contact lenses? *
No
Yes
Are you currently using eye drops of any kind, prescription or over-the-counter?*
No
Yes
Do you have a history of recurrent eye or tear duct infections?*
No
Yes
Do you have a history of dry eyes or Sjorgen’s Syndrome?*
No
Yes

List any allergies you have:

List any illnesses, medical conditions, or medical treatments you have recently received that would prohibit or compromise the process and retention of this eyelash lift:
Fifth Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Information
Have you had an eyelash lift in the past? *
No
Yes
Have you ever used hair color/eyelash tint?*
No
Yes
Have you ever had an allergic reaction to hair color/eyelash tint? *
No
Yes
Do you wear contact lenses? *
No
Yes
Are you currently using eye drops of any kind, prescription or over-the-counter?*
No
Yes
Do you have a history of recurrent eye or tear duct infections?*
No
Yes
Do you have a history of dry eyes or Sjorgen’s Syndrome?*
No
Yes

List any allergies you have:

List any illnesses, medical conditions, or medical treatments you have recently received that would prohibit or compromise the process and retention of this eyelash lift:
Sixth Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Information
Have you had an eyelash lift in the past? *
No
Yes
Have you ever used hair color/eyelash tint?*
No
Yes
Have you ever had an allergic reaction to hair color/eyelash tint? *
No
Yes
Do you wear contact lenses? *
No
Yes
Are you currently using eye drops of any kind, prescription or over-the-counter?*
No
Yes
Do you have a history of recurrent eye or tear duct infections?*
No
Yes
Do you have a history of dry eyes or Sjorgen’s Syndrome?*
No
Yes

List any allergies you have:

List any illnesses, medical conditions, or medical treatments you have recently received that would prohibit or compromise the process and retention of this eyelash lift:
Seventh Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Information
Have you had an eyelash lift in the past? *
No
Yes
Have you ever used hair color/eyelash tint?*
No
Yes
Have you ever had an allergic reaction to hair color/eyelash tint? *
No
Yes
Do you wear contact lenses? *
No
Yes
Are you currently using eye drops of any kind, prescription or over-the-counter?*
No
Yes
Do you have a history of recurrent eye or tear duct infections?*
No
Yes
Do you have a history of dry eyes or Sjorgen’s Syndrome?*
No
Yes

List any allergies you have:

List any illnesses, medical conditions, or medical treatments you have recently received that would prohibit or compromise the process and retention of this eyelash lift:
Eighth Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Information
Have you had an eyelash lift in the past? *
No
Yes
Have you ever used hair color/eyelash tint?*
No
Yes
Have you ever had an allergic reaction to hair color/eyelash tint? *
No
Yes
Do you wear contact lenses? *
No
Yes
Are you currently using eye drops of any kind, prescription or over-the-counter?*
No
Yes
Do you have a history of recurrent eye or tear duct infections?*
No
Yes
Do you have a history of dry eyes or Sjorgen’s Syndrome?*
No
Yes

List any allergies you have:

List any illnesses, medical conditions, or medical treatments you have recently received that would prohibit or compromise the process and retention of this eyelash lift:
Ninth Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Information
Have you had an eyelash lift in the past? *
No
Yes
Have you ever used hair color/eyelash tint?*
No
Yes
Have you ever had an allergic reaction to hair color/eyelash tint? *
No
Yes
Do you wear contact lenses? *
No
Yes
Are you currently using eye drops of any kind, prescription or over-the-counter?*
No
Yes
Do you have a history of recurrent eye or tear duct infections?*
No
Yes
Do you have a history of dry eyes or Sjorgen’s Syndrome?*
No
Yes

List any allergies you have:

List any illnesses, medical conditions, or medical treatments you have recently received that would prohibit or compromise the process and retention of this eyelash lift:
Tenth Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Information
Have you had an eyelash lift in the past? *
No
Yes
Have you ever used hair color/eyelash tint?*
No
Yes
Have you ever had an allergic reaction to hair color/eyelash tint? *
No
Yes
Do you wear contact lenses? *
No
Yes
Are you currently using eye drops of any kind, prescription or over-the-counter?*
No
Yes
Do you have a history of recurrent eye or tear duct infections?*
No
Yes
Do you have a history of dry eyes or Sjorgen’s Syndrome?*
No
Yes

List any allergies you have:

List any illnesses, medical conditions, or medical treatments you have recently received that would prohibit or compromise the process and retention of this eyelash lift:
Additional Information
Technician/Esthetician Performing Procedure:*
ID of Client or of Parent or Guardian (if Client is underage)
  
Valid file types: JPG, GIF, PNG, and PDF
Parent or Guardian's Driver's License / ID Card
Driver's License / ID Card Number*
Issuing State*
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Emergency Contact's Relation to Participant
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
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.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Middle Name
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Information
Have you had an eyelash lift in the past? *
No
Yes
Have you ever used hair color/eyelash tint?*
No
Yes
Have you ever had an allergic reaction to hair color/eyelash tint? *
No
Yes
Do you wear contact lenses? *
No
Yes
Are you currently using eye drops of any kind, prescription or over-the-counter?*
No
Yes
Do you have a history of recurrent eye or tear duct infections?*
No
Yes
Do you have a history of dry eyes or Sjorgen’s Syndrome?*
No
Yes

List any allergies you have:

List any illnesses, medical conditions, or medical treatments you have recently received that would prohibit or compromise the process and retention of this eyelash lift:
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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