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Are you over 18?
Have you ever had any eyelash enhancements in the past?
If so, have you ever had any of the following symptoms after receiving eyelash enhancements?
Itchy EyesEyelid SwellingEye PainExcessive redness in or around eyeEye InfectionLoss of natural eyelashes
Have you ever had your brows or lashes tinted?
Any prior adverse reaction to tinting or hair dye?
Have you had any major eye surgery?
Do you wear contact lenses?
Do you have any allergies? NoYes
If yes, to what?
Are you currently pregnant or breastfeeding?
Are you currently taking any medications (over the counter/ herbal supplements? NoYes If so, you MUST LIST ALL:
Please check the box if you have any of the following:
CancerDiabetesAlopeciaEpilepsyConjunctivitisLupusSensitive eyesThyroid DiseaseGlaucomaCataractsEyelid PsoriasisAIDS/HIVSTDCommon Cold or FluCOVIDAny Skin ConditionsWearing ContactsUsing Eyedrops
Please Check Each Box
LASH EXTENSIONS ~ I understand that this procedure requires single synthetic eyelashes to be glued to my own natural eyelashes. I understand that it is my responsibility to keep my eyes closed and be still during the entire procedure, until my eyelash technician addresses me to open my eyes. I understand that some risks of this procedure may be but not limited to eye redness and irritation. The fumes from the adhesive may cause my eyes to tear up if I open my eyes.
I agree to disclose any allergies that I may have to latex, surgical tapes, cyanoacrylate, Vaseline, etc. I understand that I am required to follow the care instructions provided by my technician in order to maintain the life of these extensions.
LASH LIFT ~ I understand that in order to have a lash lift procedure, I will need to keep my eyes closed for the duration, up to 60 minutes, during the procedure. I also understand that I will need to be lying in a reclined position. Any medical conditions that might be aggravated by lying still for a prolonged period of time may mean that I will not be able to have the procedure performed on my eyes. There are no guarantees for how long the lash lift will last, on average it is between 6-8 weeks. Madison Laser Spa is not responsible for any technician errors or reaction to the product used. I understand that the lashes will be curled with an advanced solution and a conditioning cream. I understand that opening my eyes at any point during the lash lift procedure is not recommended and may cause an undesirable result. I agree to keep my eyes closed throughout the procedure unless instructed to open them by my technician.
LASH TINT ~ I understand that a Lash Tint uses a tinting agent, developer, or mixture of both. If any solution accidentally comes into contact with my eye, my eye will be flushed with water and medical attention may be required. I will not hold Madison Laser Spa accountable for any accident or adverse reaction. Although every precaution will be made to ensure your safety and well being before, during and after your tinting application, please be aware of the possible risks. I understand that tinting lashes or brows has some inherent risk of irritation to the orbital eye area, including the eye itself, and could result in stinging or burning, blurry vision, and potentially blindness should the tint enter into the eye. I understand that there may be some residual dark staining left on the skin following the tinting process of either my lashes, brows or both. This will fade and go away within a short time. I understand that while every attempt will be made to provide me with my chosen color, everyone's hair absorbs color differently and my final results may not be the color I initially wanted. I understand that over the course of several weeks, the tint will gradually lighten and fade. Re-tinting will be required to keep the new color fresh. Most clients need to re-tint every 3-4 weeks. I understand that some irritation, itching or burning may occur to the skin which comes in contact with the tinting agent. I understand that I have been advised to follow the aftercare protocol from my technician so as to avoid any discomfort or adverse side effects after the procedure has been completed.
I give permission to show my before and after photos to other clients
I give permission to Madison Laser Spa to publish my before and after photos in house and on all social channels.
I hereby acknowledge all risks associated with performing this procedure and have been informed of possible post-procedure side effects. Any concerns I have with this procedure have been addressed by my service provider. I understand that my service provider will take all necessary precautions to prevent risks from occurring during the procedure and release them from all liability when assuming these risks. I understand that any procedure may cause eye irritation, pain, itching, rednesss or discomfort and in rare cases eye infection may occur.
I will adhere to all post procedure recommendations made by my service provider to ensure best quality of service. I certify that all above information is correct and that I have disclosed all conditions that may affect my quality of service and risks associated with my service provider. I have not withheld any information that may increase risks associated with agreed services. This agreement will remain in effect for this procedure and all future lash lift procedures continued by my technician or any other technician conducting at Madison Laser Spa. I understand that this agreement is binding and that I have read and fully understand all information above.
CLIENT BACKGROUND INFO/QUESTIONS
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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