Lash Lift & Tint Consultation + Consent Form
Client Information
Full Name
Date of Birth
Phone Number
Email
Emergency Contact Name & Number:
How did you hear about us?
Referral by Someone Social Media Website Walk-in Other
Medical History
Please check all that apply:
Eye sensitivity or dry eyes Allergies (including latex, hair dye, adhesives) Claustrophobia or difficulty keeping eyes closed Pregnancy or nursing Use of lash serums (e.g., Latisse) Contact lenses (please remove before treatment) Current use of Retinol, Retin-A, or Accutane History of eye infections (conjunctivitis, styes, etc.) Eczema, psoriasis, or dermatitis near the eyes Other medical conditions or medications:
Treatment History & Contraindications
Have you had a lash lift or tint before?
Yes No If yes, when?
Have you had any recent treatments in the eye area?
Lash extensions Chemical peels Botox or fillers Recent surgery None of the above
Have you experienced sensitivity or a reaction to any eye-area products or services in the past?
Yes No If yes, please describe:
Treatment Goals & Expectations
What are your desired results for today’s service?
Lift and curl natural lashes Darken natural lashes Natural enhancement More defined lash line Other If Other, please describe:
Any specific concerns or sensitivities we should be aware of?
Client Acknowledgement & Legal Consent
I, the undersigned, understand that lash lifting is a chemical process that alters the structure of the natural lash to enhance curl, and lash tinting involves the application of a semi-permanent dye to enhance color. I acknowledge the following:
I have disclosed all allergies, medical conditions, medications, and previous reactions that may affect the service.
I am aware that irritation, redness, stinging, and discomfort are possible, especially if aftercare is not followed.
I understand that the service requires my eyes to remain closed for the duration of the treatment (typically 45–60 minutes).
I agree to follow all aftercare instructions, including avoiding water, steam, makeup, and rubbing the eye area for 24–48 hours post-service.
I understand that results vary based on lash type, growth cycle, and lifestyle, and that repeat treatments are needed to maintain results.
I release Derma Direction and my esthetician from liability for any adverse reaction or outcome, provided the treatment was carried out in a professional and hygienic manner.
Yes, I voluntarily give my full and informed consent to receive lash lift and/or tint services at Derma Direction.
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