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LASH LIFT & TINT CLIENT CONSULTATION FORM

 -personal & confidential-

LASH LIFT & TINT CONSENT AGREEMENT

A lash lift is a procedure similar to a perm that gives you the appearance of fuller and thicker lashes without using lash extensions.

I understand and acknowledge that I am of the full age of 18 years or older. If below 18 years of age a parent or guardian must also sign this form. I confirm that I am not under the influence of alcohol or any illicit or prescription drugs which would in any way impair my ability to agree to the terms of this agreement or safely commence the procedures herein. This agreement will remain in effect for this procedure and all future procedures conducted by my technician or any other technician conducting business at Refined by Riley I understand that this agreement is binding and that I have read and fully understand all information above.

LASH LIFT & TINT CONTRAINDICATIONS

A contraindication is a condition that enables the client as unfit for this treatment. Please consult with me before the procedure if you have any of the following:

PLEASE READ AND SIGN, CONSENTING THAT NONE OF THESE APPLY TO YOU

LASH LIFT AND TINT IS NOT RECOMMENDED FOR CLIENTS WHO ARE OR HAVE ANY OF THE FOLLOWING:

-Pregnant

-Styes/ Cysts

-Blepharitis

-Chemotherapy

-Skin disease, trauma, cuts, abrasion, burns and swelling in the immediate area

-Weak lashes ( esthetician's discretion on consultation

-Skin disorders in the general eye area (Dermatitis, Xanthelasma & Syringoma)

-Eye Infections such as Impetigo or Conjunctivitis

-Eye Inflammation such as Uveitis

-Recent operations around eyes, head, or face or scar tissue in immediate areas 

-Watery eyes

-Hypersensitive skin/ eyes

-Keratitis (inflammation of the cornea of the eye)

-Alopecia (loss of hair)

-Trichotillomania (compulsive urge to pull one's hair out)

-Bells Palsy or any condition that makes closing or opening eyes difficult 

-Any disease or disorder that causes shaking twitching or erratic movements

CONTRAINDICATIONS & SPECIAL CARE - REQUIRES A GP REFERRAL

-Dry Eye Syndrome

-Glaucoma

Post Chemotherapy

FURTHER CONTRAINDICATIONS FOR CLIENT COMFORT

-Claustrophobia

-Hay fever / Rhinitis -eyes may be watery

-Contact lenses- ensure removal before the procedure



LASH LIFT AFTERCARE

1. Be gentle with lashes, no rubbing the eyes

2. Do not tough eyelashes with fingers (spoolie only)

3, Do not get your lashes wet for the first 24-48 hours

4. Do not use harsh products on your eyes / lashes

5. The use of sauna/ steam is possible after 24 house but may weaken the effect of the lift

6. No eye makeup for 24 hours

7. Avoid waterproof mascara to prolong your lash lift

8. Avoid sleeping on your lashes for 24 hours.

I acknowledge reading the aftercare instructions and I will try and follow these instructions to the best of my ability.

I Agree


I UNDERSTAND / AGREE TO THE FOLLOWING COMPLETELY :

I consent to the procedure of an Eyelash lift and lash tint.

I Agree

I understand that as part of the procedure, eye irritation, eye pain, eye itching, discomfort, and rare cases, eye infections or blurriness could occur. I agree that if I experience any of these medical conditions, I will contact Refined by Riley and consult a physician at my own expense.

I Agree

I understand that even though Refined by Riley lifts my lashes using the proper technique, instruments, tapes, cleaners, eye gel pads, adhesives, and removers eye irritation may occur.

I Agree

I understand and agree to the home care instructions provided by Refined by Riley for the use and care of permed/ and or tinted lashes.

I Agree

I realize and accept the consequences of failure to adhere to the aftercare instructions may cause the lashes to nor stay permed as long as told.

I Agree

I understand and consent to having my eyes closed and covered for the duration of the 60-90 minute procedure.

I Agree

I release Refined by Riley from all liability associated with this procedure, which is performed with the utmost attention to safety and proper application using tools and products that Refined by Riley has been professionally trained to use.

I Agree

I understand there are no guarantees for the length of time the lashes will stay permed.

I Agree

I understand the aftercare instructions and will do my part to maintain my results.

I Agree

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

I Agree

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


PHOTOGRAPHIC, AUDIO, OR VIDEO RECORDINGS MAY BE USED FOR THE FOLLOWING PURPOSES:

I hereby grant permission to the rights of my image, likeness, and sound of my voice as recorded in audio or video tape without payment or any other consideration.

I understand that my image may be edited, copied, exhibited, published, or distributed. I waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any rights to royalties or other compensation arising or related to the use of my image or recording. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area.

PHOTOGRAPHIC, AUDIO, OR VIDEO RECORDINGS MAY BE USED FOR THE FOLLOWING PURPOSES:

-Educational presentations or courses

-Informational presentations

-Online educational courses

-Educational videos

-Promotional materials 

By signing this release, I understand the permission signifies that photographic or video recordings of me may be electronically displayed via internet.

By signing this form, I acknowledge that I have completely read and fully understand the above release and agree. I hereby release any and all claims against any person or organization utilizing this material for educational purposes

Please select who will be participating...
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First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Parent or Guardian's Email Address

Email
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
How did you hear about us?

How did you hear about us? *
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*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
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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