Lash lift waiver and release form



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Date19.12.2017
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LASH LIFT WAIVER AND RELEASE FORM
I authorize (your business name) technician to perform the Lash Lift procedure. I understand the Lash Lift procedure is as follows:


  • Lashes are cleaned

  • Bottom lashes are covered with tape

  • A silicon Pad is glued to the eyelid with a water soluble glue

  • Lashes are lifted on the pad with glue

  • The following solutions are applied to the lashes that are lifted on the pad (one at a time for a minimum of 10 minutes and a maximum of 20 minutes): Perm Lotion, Setting Lotion, and Nourishing Oil

  • Lashes are cleaned

  • Optional Lash Tint is applied

I understand that it is my responsibility to be still during the procedure and to keep my eyes closed during the process unless otherwise advised. Eyes and the skin around them are extremely delicate, and can incur damage, including irritation, burning and allergic reaction to the products used to lift the lashes and/ or the tape, anti-wrinkle gel patches or black eyelash tint. These reactions can include anything from mild irritation to a full-blown allergic reaction, even blindness. I have been fully informed as to the methods and procedures concerning the Lash Lift procedure and the risks of the cosmetic procedure I have chosen have been disclosed to me.


Although it is impossible to list every potential risk and complication, the following conditions are recognized as contraindications for the Lash Lift and Tint treatment and must be disclosed prior to the treatment:

  • Eye Infections/disorders

  • Recent Eye Surgery

  • Allergy to product

  • Very sensitive eyes

  • Hay fever sufferers/Watery Eyes

  • Conjunctivitis

  • Stye

  • Dry Eye Syndrome

  • Using prescribed medicated eye drops

  • Pregnancy - during the 1st trimester

  • Medication - Thyroxin (in some cases can prevent lashes from curling)

  • Contact Lenses - must be removed

If at any time I (or the technician) are uncomfortable with the Lash Lift procedure, I will inform the technician and s/he will gladly rectify the problem, including ending the session if I (or the technician) wishes. It has been represented to me that no guarantees, warranties, promises, commitments or other statements as to the results of this treatment have been made. I acknowledge that I have no particular representation or guarantees and I am consenting to the procedure at my own risk. All conditions must be revealed or disclosed by me to the technician regarding my health history, medications being taken and any past reactions to products used or medications taken. Additional conditions could be discovered during the procedure, which could affect my ability to tolerate the procedure.

I herein sign, release, give up, acquit, and discharge my technician from (your business name) and or anyone affiliated there to including any partnership, corporations, or company associated with said individual from any claims or damages of any nature. I agree to pay any costs of legal services necessary to affect said release. I further agree that this release shall be in contemplation of any possible damages, either known or unknown at the signing of this release and said damages are specifically waived following the signing of this release. I further agree that in the event any litigation ensues, it shall be placed before the American Arbitration Association or some other such arbitrator for resolution. I agree that in the event a decision is determined in favor of one party over the other, the prevailing party shall be entitled to reasonable attorney fees and costs as set by the arbitrator. I further agree to hold (your business name) professional nameless and harmless from any and all damages. I release my (your business name) professional from any responsibility for pre-existing conditions I have not revealed or any consequential change to those conditions that arise subsequent to the procedure. I accept full responsibility for these and any other complications, which may arise or result during or following the Lash Lift procedure(s), which are to be performed at my request.
Please read the following statement and sign and date on the line to indicate that you have read the statement and understand it: I, the client herein signed, certify that I have read and had explained to me and fully understand the above waiver and release form. I certify that I have consulted with (your business name) professional.
I have provided information regarding my health and medications taken to the best of my knowledge. I accept the explanation of potential complications and risks described herein. I certify I am of sound mind, and fully understand that there might be other unknown risks not reasonably foreseeable at this time.
I the client herein signed, for the purposes of documentation, hereby consent to “before and after” photographs, which may or may not be used for the purposes of advertising.

Print Name: ___________________________ Signature: _______________________________


Address/City/State/Zip Code: _____________________________________________________
Date: ________________ Email: __________________________ Phone: __________________

Client Medical History Form

Date___________ Birth Date_____________

Name:____________________________________________________________________________

Address:__________________________________City__________________State______Zip______

Phone #________________________Email______________________________________________

Emergency contact person________________________________Phone#_____________________
Do you presently have or previously had any of the following: (Circle yes or no)

Yes No Eye Infections/disorders

Yes No Recent Eye Surgery

Yes No Allergy to product

Yes No Very sensitive eyes

Yes No Hay fever suffer/watery eyes

Yes No Conjunctivitis

Yes No Stye

Yes No Dry Eye Syndrome

Yes No Using prescribed medicated eye drops

Yes No Pregnancy – during first trimester

Yes No Medication – Thyroxin (could prevent lashes from curling)

Yes No Contact lenses (must be removed)

Yes No Allergy to dye or tint

Yes No Any diseases or disorders not listed: ______________________________________________
Please list medication or vitamins you’re presently taking: ___________________________________

I agree that all the above information is true and accurate to the best of my knowledge.



Signed:___________________________________________________________Date________________

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