LASH WAIVER Name * First Name Last Name Address Date of Birth Phone (###) ### #### Email * PREVIOUS DISCOMFORT, STINGING OR ADVERSE REACTIONS: Please tick any that apply: Skin Disorders Eye infections Watery eyes Bell’s Palsy Allergies to Latex/band aids Inflammation of the skin Recent eye surgery Hay Fever Previous reactions to eye treatments Allergies to glue/bonding agents/adhesives Eye Disease Blephartitis Allergies Contact Lenses Allergies to acetone Are you pregnant/lactating? Are you taking HRT? Are you on the contraceptive pill? Any medications? Other relevant information: Have you had Lash or brow tinting, lash lifting, lash perming, eyelash extension or semi-permanent mascara applied previously? Yes No Information: AGREEMENT: I request and consent to these procedures being carried out today without undergoing a sensitivity patch test. The sensitivity test, which if conducted may indicate my sensitivity / allergy to the products. I understand the contents of this form and take full responsibility for my actions, thus absolving all other parties of their responsibilities, if any, associated with the supply of the products and services(s). First Name Last Name Date MM DD YYYY Thank you!
