LASH LIFT INDEMNITY FORM Please enable JavaScript in your browser to complete this form.1Information2AgreementPlease read and complete this form carefully. Questionnaire: By signing this authorization form, you declare that the answers given herein are true and complete to the best of your knowledge. False or misleading answers can lead to complications and/or undesirable results. Please indicate your answer by selecting per question and provide detail where appropriate. Previous discomfort, stinging or adverse reactions: Please tick any that applySkin disordersInflammation of the skinEye diseaseEye infectionsRecent eye surgeryBlephartitisWatery eyesHay FeverAllergiesBell's PalsyPrevious reactions to eye treatmentsContact LensesAllergies to Latex/band aidsAllergies to glue/bonding agents/adhesivesAllergies to acetoneAre you pregnant/lactating?Are you on the contraceptive pill?Are you taking HRT?Any medications: *Other relevant information: *Have you had Lash or brow tinting, Lash Lifting, Lash perming, Eyelash extension or semi-permanent mascara applied previously? *YesNoNextClient Name *FirstLastLayoutDate of Birth *Phone *Address *Email *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). Client Signature *Clear SignatureAuthorized Signature for TIPS N TOES LTD. *Clear SignatureTIPS N TOES LTD *FirstLastDate *GDPR Agreement *I consent to having Tips N Toes store my submitted information.Send me a copy.PreviousSubmit
