Service Consent Form Your Name * First Name Last Name Email * Phone * (###) ### #### Emergency Contact Name * First Name Last Name Emergency Contact Phone * (###) ### #### Do you have any allergies? * Latex, adhesives, skincare ingredients, etc.? Do you have any skin conditions? * Acne, eczema, rosacea, sensitive skin, etc.? Are you currently using any of the following? * Check all that apply Retinol / Retinoids Accutane (or past use within the last 6 months) Alpha Hydroxy Acids (AHAs) or Beta Hydroxy Acids (BHAs) Prescription skincare Have you had any cosmetic procedures in the last 6 months? * Botox, fillers, laser treatments, etc. Do you have any eye conditions? * Dry eye, infections, surgeries, contact lenses, etc. What is your current at-home skincare regimen? * Products, frequency, etc. Service Selection * Check all that apply Dermaplaning Chemical Peel Facial Lash Extensions Lash Lift & Tint Other I acknowledge and understand that * The services provided involve potential risks, including but not limited to irritation, allergic reactions, or undesired results. I have disclosed all known allergies, sensitivities, and medical conditions relevant to these services. I will follow all aftercare instructions provided by my service provider. I release the service provider and establishment from any liability or legal action in the event of an adverse reaction. I voluntarily consent to receive the selected services Date * MM DD YYYY E Signature * First Name Last Name Thank you! Your form is now in our files!
