Eye Makeover Consent Form Name : * First Name Last Name Guardian's Name : (in case when the client is a minor) First Name Last Name Phone : * (###) ### #### Email : I hereby, agree to have an eye makeover procedure performed on my brows and lashes. By signing this agreement, I consent to the Eye Makeover procedure by a Brows on Fleek technician. I understand that on rare occasions there are risks associated with having the eyebrow tinting dye and having artificial eyelashes/ eyelash extensions applied to my natural lashes and eyebrows. I further understand that in rare cases as part of the procedure eye irritation and discomfort could occur as a result of the use of the instruments, tapes, cleaners, eye gel pads, adhesives and/or removers. I agree that if I experience any of these conditions with my lashes and/or eyes that I will contact the certified technician that performed this procedure and that it may be beneficial to contact emergency medical services without delay, at my own expense. I understand and agree to the after-care instructions provided by the certified technician for the use and care of my lashes and eyebrows. I realize and accept the consequences of failure to adhere to these instructions may cause eyelash extensions to fall out and/or decrease the time the lashes and tinting will last. I understand and consent to having my eyes closed and covered for the duration of approximately 60-90 minute procedure. Times may vary depending on the thickness of lashes. I am informing the certified technician of the following conditions by marking with a check: • Current use of contact lenses which I may be asked to remove during the procedure. • Current use of anything such as oil-containing sunscreen or moisturizer around the eyes. • Current use of eye drops of any kind, prescription or over the counter. • Current allergies or sensitivities. • 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 placement and retention of eyelash extensions. • Others (please specify) I agree to the following eye makeover follow-up and maintenance instructions: • No waterproof mascara. • No oil-based products around the eye area. • No water can come in contact with the eye area for 24 hours after the completion of procedure. • No pulling or rubbing of the eyelashes. • Should any kind of eye drops be necessary extra care should be taken to prevent moisture from coming into contact with the eyelashes. • Any allergies (please specify): This agreement will remain in effect for this procedure and all future follow-ups conducted by the certified technician, and will hold the technician/s harmless from any liability that may result from this procedure. I read English and understand that this consent agreement is legal and binding. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above agreement clauses, and that I have had sufficient opportunity for discussion to have all my questions answered. I understand the procedure and accept the risks. I do not hold the technician responsible for any of my conditions that were present, but not disclosed at the time of this procedure that may be affected by the treatment performed today. I agree that I will not hold Brows on Fleek or its affiliates or any of its employees responsible should there be any unfavorable outcome or result. Date : * MM DD YYYY Thank you!
