Lash Lift & Tint Intake and Consent Form

**Please arrive without eye makeup to your appointment and don't wear contacts!**

Bring your case with you and a pair of back up glasses to wear after the lash lift/tint.

What A Lash Lift & Tint Is?

A lash lift and tint is a beauty treatment that enhances your natural eyelashes by curling and darkening them. A perming solution is used to lift and curl your lashes from the base, and a semi-permanent dye is applied to darken the lashes, giving your eyes a defined open-eyed look.

Acknowledgment of Risks

By checking and initialing below, I acknowledge and accept the following:

1. Potential Risks

✦ Lash lift and tint involve the use of perming and tinting solutions. While these are safe for most clients, there is always a possibility of an allergic reaction, blurriness, irritation, redness, swelling, or discomfort due to individual sensitivities.

✦ Loss of natural lashes and sensitivity to light.

✦ These reactions are not indicative of improper application or malpractice but are dependent on the client's unique skin, hair, and health conditions.

I confirm that I have read, understood, and accept the potential risks

2. Product Ingredients

The solutions used in this procedure may include, but are not limited to:

✦ Lash Lift Solution: Water, Thioglycolic Acid, Ammonium Hydroxide, Ethanolamine, Cetyl Alcohol, Sodium Bromate.

✦ Neutralizing Lotion: Water, Sodium Bromate, Cetearyl Alcohol, Polysorbate 20, Hydrogen Peroxide.

3. Aftercare and Maintenance

✦ I understand and accept that proper aftercare (avoiding wetting the lashes, heat, sweat, and makeup for 24-48 hours) is essential to maintain results.

✦ Results may vary based on the condition of my lashes and adherence to aftercare instructions.

I confirm that I have read, understood, and accept the aftercare and maintenance

4. Optional Patch Test

There are a small number of individuals who may have an allergic reaction to tints, hair dyes, and other chemical treatments. It is only in rare situations that the reaction can be severe. If you've ever gotten a rash from an allergic reaction to hair dye containing para-phenylenediamine (PPD), then you may also develop an allergic rash to lash or brow dyes and should not use them. We offer a complimentary patch test service for all clients. Please request an additional patch test if you would like to check your sensitivity, which should be performed 48 hours prior to your appointment. We thank you for your cooperation to ensure your comfort and safety.

Would you like the optional Patch Test?

Initials

Please read each statement, initial in each box, and sign this document to accept your acknowledgement and agreement of the following:

I affirm that I am 18 years of age or older, and competent to sign this release on my own behalf. I have read and fully understand and accept this agreement and all information detailed throughout this consent and intake form. I understand the service and accept the risks. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold the technician and or Kate Aglaia Aesthetics owner responsible for any of my conditions that weren’t disclosed at the time of the skin care service, which may be affected by the treatment performed. I understand that this agreement will remain in effect for this procedure and all future procedures conducted by my technician. Although it is impossible to list every potential risk and complication, I have been informed of possible risks and complications. I have also, to the best of my knowledge, given an accurate account of my medical history, including known allergies or prescription drugs or products I am currently ingesting or using topically. I understand and accept the nature and purpose of the products to be used in this service has been explained to me, along with the risks and hazards involved.

Signature

To be signed by parent/guardian if the participant is under 18

Today's Date

Full Name

Date of Birth

Month

Day

Year

Phone

Address

Any medications, including those that may affect skin sensitivity or hair growth in the last 12 months

Are you pregnant or lactating?

Do you have any allergies to latex, glues, adhesives, perming solutions, bonding agents, acetone, or hair dyes?

Have you had any of the following within the last 2 years?

None

Tinting

Eyelash Perm or Lift

Eyelash Extensions

Have you had any previous reactions to eye treatments?

If yes, please explain

Any other relevant information we should be aware of?

How did you hear about us?

I hereby consent to and authorize Kate Aglaia Aesthetics to perform a Lash Lift and/or Lash Tint and to have my eyes closed and covered for the duration of the 45-90 minute procedure.

I give Kate Aglaia Aesthetics permission to take photos of my treatment for before-and-after comparison, educational purposes, marketing (social media), and documentation.

I understand and accept that there are risks associated with having my eyelashes permed and/or tinted. I understand that no warranty, guarantee, or assurance has been made to me as a result of the Lash Lift and Tint technique and that the final result cannot be guaranteed as each skin type and hair is unique. I further acknowledge that, as part of the procedure, eye irritation, eye pain, itching, discomfort, allergic reactions, and, in rare cases, eye infection or blurriness may occur. I agree that if I experience any of these conditions during or after the procedure, I will notify Kate Aglaia Aesthetics and consult a physician at my own expense.

I fully release my technician & Kate Aglaia Aesthetics from any liability related to this procedure, during & after its completion. The procedure will be performed with utmost safety & proper technique, using tools & products the technician is trained in.

Signature

Today's Date

I understand payment is due in full at the time of service. Cancellations or rescheduling must be made 48 hours in advance, or a 50% charge applies. No-shows are charged 75%. Late arrivals (10+ mins) incur a no-show fee and must reschedule.