Lash Lift Consent Form Step 1 of 3 33% CONTACT INFOName* First Last Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Date of Birth*Please enter mm/dd/yyyy MM slash DD slash YYYY How did you hear about Reveal Sacred Skincare?* EYE HEALTHI understand the risks associated with having a Lash Lift. I furthur understand that as a part of the procedure, eye irritation, eye pain, eye itching, discomfort, and in rare cases; eye infection or blurriness could occur. I understand that even though Reveal Sacred Skincare lifts the lashes using the proper technique, the instruments, tapes, cleaners, eye gel pads, adhesives, and removers used may irritate my eyes.* I am informing Reveal Sacred Skincare of the following conditions:* Current use of contact lenses which I agree to remove before application Current use of anything such as oil-containing sunscreen or moisturizers around the eyes Current use of eye drops of any kind, prescription or OTC Current allergies or sensitivities to instruments, fumes, tapes, cleaners, eye gel pads, adhesives, and removers that could cause my eyes to water and blink in excess. If so, I agree to schedule a patch test at least 48 Hours before scheduling my Lash Lift Service. History of recurrent eye or tear duct infections History of dry eyes or Sjorgen's Syndrome Recent history of Chemotherapy Other medical conditions which would prohibit or compromise the process and retention of this lash lift Previous reactions to eye treatments Allergies to adhesives, glue, or bonding agents None of the above IMPORTANT DETAILSI agree to not wear mascara to my Lash Lift appointment. Failure to remove mascara may compromise the results of my Lash Lift.* I agree to keep my eyelashes dry for 24 hours following the procedure.* I do not have eye surgeries scheduled within 72 hours of my Lash Lift* CONSENT AND POLICIESI agree to have a Lash Lift applied to my natural eyelashes.* I understand and consent to having my eyes closed and covered for the duration of the 45-60 minute procedure.* By signing, I confirm that I understand the questions asked and information given are confidential and relevant to my treatment and that, to the best of my knowledge, my answers are accurate.*To confirm, please initial in the space provided immediately below each of the statements. GUARANTEE: I understand that there are no guarantees for length of time lashes will stay lifted and results may vary. I understand that there are many factors that may affect the life of the Lash Lift, such as water and moisture contact, weather conditions, and activities that involve exposure to high temperatures.* CLIENT RESPONSIBILITY & COMMUNICATION: I agree that if I experience any allergic reactions, infection, or medical conditions with my lashes that I will contact Reveal Sacred Skincare and consult a physician at my own expense.* CLIENT RESPONSIBILITY: I understand that it is my responsibility to keep my service provider informed and updated should any of the above information change.* CANCELLATION POLICY: I understand that I need to cancel or reschedule my appointments at least 24 hours in advance or I will be charged IN FULL for my missed services, regardless of circumstances. I know that I can manage my own appointments online 24/7 and that if I choose to call, text, or email to cancel my apointment outside of business hours and that message is not received in time, I will be charged.* I release Reveal Sacred Skincare from all liability associated with this procedure, which is performed with the utmost attention to safety and proper application using the tools and products that the technician has been professionally trained to use. This agreement will remain in the effect for this procedure and all future procedures conducted by Reveal Sacred Skincare. I have read and fully understand all information in this agreement. I consent to the agrement and to treatment. By signing, I verify I have read, understand, and agree to all the above statements. Please write your full name below in lieu of a signature.* Today's date*Please enter mm/dd/yyyy MM slash DD slash YYYY
