MOD Skin and Body

LASH LIFT cONSENT- rELEASE & WAIVER OF lIABILITY fORM

I agree to have an eyelash lift (perm) and/or eyelash tint applied to my natural eyelashes and/or retouched. By signing this agreement, I consent to the procedure of an eyelash perm or eyelash tint by my technician. I understand there are risks associated with having an eyelash perm and/or eyelash tint. I further understand that as part of the procedure, eye irritation/reaction, eye pain/injury, eye itching, discomfort, and in rare cases eye infection or blurriness could occur. I agree that if I experience any of these medical conditions with my lashes that I will contact my technician and consult a physician at my own expense. I understand that even though my technician perms the lashes using the proper technique, the instruments, tapes, cleaners, eye gel pads, adhesives, and removers used may irritate my eyes or require a physician’s follow-up care. I understand and agree to the care instructions provided by my technician for the use and care of my permed and/or tinted eyelashes. I realize and accept the consequences of failure to adhere to these instructions may cause the eyelashes to not stay permed as long as told. I understand and consent to having my eyes closed and covered for the duration of the 60-75 minutes procedure.

I am informing my technician of the following conditions by marking with a check:

Current use of contact lenses which I agree to remove during application _______

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

Current use of eyedrops of any kind, prescription or over the counter _______

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 _______

History of recurrent eye or tear duct infections _______

Recent history of Chemotherapy _______

Other medical conditions which would prohibit or compromise the process and retention of this eyelash perm _______

I agree to the following eyelash perm post-op and maintenance instructions: No water can come in contact with the eye area for 24 hours after the application. This agreement will remain in effect for this procedure and all future procedures conducted by my technician. I read English and understand that this consent agreement is legal and binding. 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 treatment. I release my technician from all liability associated with this procedure, which is performed with the utmost attention to safety and proper application using tools and products that the technician has been professionally trained to use.

There are no guarantees for length of time the lashes will stay permed. I understand the aftercare instructions and will do my part to maintain my eyelashes. I understand that there are many factors that may affect the life of the eyelash lift such as water and moisture contact, weather conditions, and activities involving exposure to high temperatures. By signing below, I verify that I have read and understand the above statements and agree to them and hearby assume all risks associated with the service.