Consent for Lash and Brow Services – Celebrity Skin Studio

Date*

Name*

First Last

Phone*

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Current Age*

If you are a minor, in addition to this form, you must fill out a General Intake & Waxing consent form, including the parental consent portion. This form is located on the website under the FORMS tab.

Date of Birth*

Do you wear contacts?*

Yes
No

If you are receiving a lash treatment (lift or tint) you will need to arrive with contacts removed. It is suggested to wear glasses after treatment if possible.

Have you had an eyelash lift, tint or brow lamination in the past?*

Yes
No

If yes, when?

Please list the procedure you had and when.

Have you ever had an allergic reaction to any the procedures below*

lash lift, lash tint, hair perm or hair color

Yes
No

If so please indicate which one you had reaction to and what the symptoms were.

Have you ever had an allergic reaction to any adhessives?*

Such as eyelash glue or nail glue.

Yes
No

If so please indicate which one you had reaction to and what the symptoms were.

Within the last 2 months have you had lash extensions or any procedure done to your lashes? If yes indicate WHEN and WHAT the service was. If you had lashes removed indicate how they were removed ie, fell off naturally, removed by professional, removed by yourself.

List any illnesses, medical conditions, or medical treatments you have recently received that would prohibit or compromise the process and retention of any of these services.*

If there are none please list N/A

PRE TREATMENT INSTRUCTIONS: Please arrive with no make up, or products on the area to be treated, this includes areas above or below the eye area. Please make sure that lashes or brows have been thoroughly cleaned removing any debris, make up or product. This will ensure good product penetration. Any oil based cleansing products should be avoided as they leave a residue. For lash services, contacts must be removed prior to appointment. It is suggested that you wear glasses instead of contacts to and from your appointment. If you are sensitive to caffeine please avoid before your appointment. Please note if your eyes tear or water excessively it may prevent your service provider from being able to apply products.

I agree to comply to the above pre treatment instructions.

POST Treatment Instructions: Areas treated should be kept dry for 24 hours after treatment.

I agree to comply to the above post treatment instructions.

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 treatments/procedures 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 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, 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 I agree to update my service provider of any changes to this form. I understand photos may be taken for documentation purposes and may be used in promotional materials and social media posts.

Signature*

Date*

Lash and Brow Chemical Service Consent For Lifts, Tints & Lamination Services

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