Lash Lift Waiver

Name *

First Name

Last Name

Phone

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###

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I agree to have a Lash Lift Service performed on my natural eyelashes. By signing this agreement, I consent to the Lash Lift and/or Tint by the certified Lash Lift professional. *

Yes

No

I understand that in rare occasions there are risks associated with having a Lash Lift and/or Tint treatment. *

Yes

No

I further understand that in rare cases as part of the procedure eye irritation and discomfort could occur. *

Yes

No

I agree that if I experience any of these conditions with my lashes that I will contact the certified Lash Lift professional that performed this procedure. *

Yes

No

I understand that results will vary and that if the lash lift is not to my liking that I will contact the certified Lash Lift professional within 48 hours for a potential additional appointment. *

Yes

No

I understand and agree to the after-care instructions provided by the certified Lash lift professional for the use and care of my eyelash Lift and/or Tint. *

Yes

No

I realize and accept the consequences of failure to adhere to these instructions may impact the Lash Lift and/or Tint and that the Lash Lift professional is not responsible for the results of this. *

Yes

No

I understand and consent to have my eyes closed and covered for the duration of approximately 45-75 procedure. *

Yes

No

I am informing the certified Lash Lift professional of the following conditions by marking with a check: *

Contact lenses must be removed prior to lash service

Current use of anything such as oil-containing sunscreen or moisturizers around the eyes

Current use of eye drops of any kind, prescription or over-the-counter

Current allergies or sensitivities

History of an allergic reaction to Hair dye or tints.

History of dry eyes or Sjorgen’s Syndrome

Recent history of Chemotherapy

Lasik Eye surgery within the last year

Watery Eyes

Thyroid Issues

Hormonal Imbalances

Other medical conditions which would prohibit or compromise placement and retention of eyelash extensions

Allergy to Strip Lash Glue

None of the Above

I agree to the following after-care instructions, please check each box: *

No waterproof mascara

No Mascara for 12 hours

No water can come in contact with the eye area for 12 hours after the application

No use of pool/ sauna or spa for 48 hours after the application No tinting or perming of eyelash extensions

Avoid rubbing eyes excessively for the first 12 hours

Avoid putting pressure on face/lashes for at least 24 hours

Avoid sleeping on the face

Have you ever experienced discomfort or any adverse reaction to eyelash extensions in the past? *

Yes

No

I acknowledge that I must adhere to Sam Tran Beauty & Wellness’ policies. I understand that cancellations must be done with at least 24 hours notice Failure to do so will result in the loss 30% of the total service cost. *

Yes

I release Sam Tran Beauty & Wellness and its staff of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products. *

Yes