BROW & LASH CONSENT FORM Please take the time to read this form and complete it before your service. This form does not need to be completed again unless it is updated, ๐๐๐๐๐ก๐ง ๐๐ก๐ง๐๐๐ ๐๐ข๐ฅ๐ & ๐๐ข๐ก๐ง๐๐๐ง ๐๐ก๐๐ข๐ฅ๐ ๐๐ง๐๐ข๐ก Name * First Name Last Name Today's Date * MM DD YYYY Phone Number * (###) ### #### Email Address * Date of Birth * MM DD YYYY Age * Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact * (###) ### #### ๐ ๐๐๐๐๐๐ ๐๐๐ฆ๐ง๐ข๐ฅ๐ฌ ๐๐ก๐๐ข๐ฅ๐ ๐๐ง๐๐ข๐ก Please select any and all contraindications below that may apply to you. Lash Extension, Lift & Tint Contraindications: Dry Eye Syndrome Ocular Rosacea Sjorgen's Syndrome Chemotherapy History Of Eye infection Sjorgen's Syndrome Brow Lamination & Tint Contraindications: Alopecia Wounds In Treatment Area Recent Facial Treatment (chemical peels/laser) Psoriasis History Of Eye infection Super Sensitive Skin Eczema Sunburn Retinol, AHA, BHA etc. Do you have any know allergies to adhesives, fumes or removers? * No Yes Have you had previous allergies/sensitivities to lash extension, lash lift, tint or brow lamination products? * No Yes Are you pregnant or breastfeeding? * No Yes Do you wear contacts? * No Yes Do you use eye drops of any kind? * No Yes Do you use oil-containing sunscreen or moisturizer around the eyes? * No Yes Please List any medications/supplements you take regularly: Have you recently had lash extensions/lash lift or brow lamination? * No Yes If YES to the above, when did you have this done? Have you recently had any semi-permanent makeup procedures done? * ie. micro-blading, nano/powder brows, tattoo liner. No Yes If YES to the above, when did you have this done? I consent to have my eyes closed and covered for the duration of the 45-90 minute procedure. No Yes My typing my full name in the space below, I agree to the following: I am over 18 years of age and have completed this form truthfully and to the best of my knowledge. I agree to inform Stephanie Rorke of any changes in the above information. I agree that I do not have any condition/s that would make the requested treatment unsuitable. I agree to waive and and all liabilities toward my technician for any injuries, loses, damages or claims incurred due to any misrepresentation of my health. * * By typing my full name in the space below, I hereby give consent to Stephanie Rorke to perform the following services: lash extensions, brow lamination, brow tint, lash lift, lash tint and facial waxing services. ๐ฆ๐๐ฅ๐ฉ๐๐๐ ๐๐ข๐ก๐ฆ๐๐ก๐ง ๐๐ข๐ฅ๐ ๐๐๐ฆ๐ ๐๐๐๐ง & ๐ง๐๐ก๐ง/๐๐ฅ๐ข๐ช ๐๐๐ ๐๐ก๐๐ง๐๐ข๐ก & ๐ง๐๐ก๐ง ๐ฃ๐น๐ฒ๐ฎ๐๐ฒ ๐ถ๐ป๐ถ๐๐ถ๐ฎ๐น ๐๐ต๐ฒ ๐๐ฝ๐ฎ๐ฐ๐ฒ๐ ๐ฝ๐ฟ๐ผ๐๐ถ๐ฑ๐ฒ๐ฑ ๐๐ผ ๐ฐ๐ผ๐ป๐ณ๐ถ๐ฟ๐บ ๐๐ผ๐ ๐ต๐ฎ๐๐ฒ ๐ฟ๐ฒ๐ฎ๐ฑ ๐ฎ๐ป๐ฑ ๐๐ป๐ฑ๐ฒ๐ฟ๐๐๐ฎ๐ป๐ฑ ๐ฒ๐ฎ๐ฐ๐ต ๐๐๐ฎ๐๐ฒ๐บ๐ฒ๐ป๐. By initialing the below, I consent to the procedure of eyelash extensions, an eyelash lift/tint and/or brow lamination/tint on my natural eyelashes and/or brows by Stephanie Rorke. * I understand there are risks associated with having an eyelash perm, brow lamination and/or eyelash tint. I further understand that as part of the 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 medical conditions with my lashes that I will contact Stephanie Rorke and consult a physician at my own expense. * I understand that even though my technician applies/perms the lashes/brows using the proper technique, the instruments, tapes, cleaners, eye gel pads, adhesives, and removers used may irritate my eyes/brows or require a physicianโs follow-up care. * I understand that some mild but normal symptoms may occur with the brow lamination depending on the sensitivity of my skin during the procedure and will subside in 24 hours. These symptoms may include: mild tingling, slight redness due to brushing the hairs, slight warmth in the area. * I understand that this agreement will remain in effect for this procedure and all future procedures conducted by my technician. * I have been offered the opportunity to have a patch test of the brow lamination and/or lash lift products being used. I accept full responsibility for any reaction which might occur due to undisclosed sensitivities/allergies. * I understand and consent to having my eyes closed throughout the procedure. * I will remove any contact lenses before the procedure. * I understand that if I have any concerns, I will address these with my lash/brow technician. * ๐๐๐ฅ๐๐๐ ๐๐ก๐ง ๐๐๐๐ก๐ข๐ช๐๐๐๐๐๐ ๐๐ก๐ง This agreement will remain in effect for this procedure and all future follow-ups conducted by the certified eyelash/brow technician. I understand my lash/brow technician will take every precaution to minimize or eliminate negative reactions as much as possible. I will hold him/her and his/her staff harmless and nameless from any liability that may result from this treatment. I certify that I have read, and fully understand, the above information 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 Stephanie Rorke responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today. I have read and fully understand all information in this agreement. I am over 18 years of age and consent to the agreement and to the eyelash lift/tint/brow lamination procedure. ๐๐๐ฆ๐ ๐๐๐๐ง & ๐ง๐๐ก๐ง/๐๐ฅ๐ข๐ช ๐๐๐ ๐๐ก๐๐ง๐๐ข๐ก & ๐ง๐๐ก๐ง ๐๐๐ง๐๐ฅ๐๐๐ฅ๐ I agree to the following Lash Lift/Tint/Brow Lamination aftercare and maintenance instructions: - No water can come in contact with the treatment area for 24 hours after the application. - No makeup such as mascara, eyeliner or brow pencil on the treatment area for the first 24 hours. - No skincare products or oil containing products on or around lashes/brows for the first 24 hours. - No waterproof mascara on your lifted/tinted lashes. *If redness or irritation worsens over the course of 24 hours please contact your doctor about a potential reaction to the product. - Do not have any type of permanent makeup or semi-permanent makeup done while your hair is still lifted, as your artist must be able to see the natural direction of the hair. - No pulling or rubbing of the lashes/brows. Typing my name below signifies that I understand and agree to the care instructions above for the use and care of my permed and/or tinted eyelashes/eyebrows. I realize and accept the consequences of failure to adhere to these instructions may cause the eyelashes/eyebrows to not stay permed and/or tinted for as long as told. If you have filled out this form on behalf of a minor (under 17 years old) Please type their full name below. Thank you!
