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Informed Consent: Eyelash Lift

Have you had an eyelash lift in the past?
Have you ever used hair color/eyelash tint?
Have you ever had an allergic reaction to hair color/eyelash tint?
Do you wear contact lenses?
Are you currently using eye drops of any kind, prescription or over-the-counter?
Do you have a history of recurrent eye or tear duct infections?
Do you have a history of dry eyes or Sjorgen’s Syndrome?
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. By selecting the checkboxes below you agree to the risks and post care of an eyelash lift.

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.

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