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Home
About
- About Us
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Contact

913-441-9090
clients@lavitabelladayspa.com

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Home › Forms › Lash Lift Consent Form

La Vita Bella Lash Treatment Consent Form

The Lash Lift treatment will instantly give your lashes lift, separation, and extra definition without the use of extensions. This gentle alternative to lash extensions essentially takes the natural hairs you have lining your lid and gives them a dramatic curl. This is NOT intended to straighten lashes.

Please avoid any mascara or moisture for the next 24 hours to help maintain curl.

Client Name:

Phone:*

Email:*

Have you experienced any of the following within the last 3 months:*

Skin Disorders Eye Infections / Disease Watery Eyes Bell's Palsy Seasonal Allergies Inflammation of the Skin Recent Eye Surgery Contact Lenses Hair Loss Blephartitis

Are you pregnant or lactating?:*

Yes No

Due Date:*

Do you have any allergies to latex, adhesives, glues, or bonding agents:*

Yes No

Any medications:

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

Tinting Eyelash Perm or Lift Eyelash Extensions Semi Permanent Mascara

Have you had any previous reactions to eye treatments?:*

Yes No

Did you seek medical advise from a doctor or specialist as a result of this action?:*

Yes No

Any other relevent information we should be aware of?:

Choose One:*

I have filled this form out for myself. I have filled this form out to the best of my knowledge for my significant other, adult child or parent, over the age of 18 I have filled this form out for my minor child, and I give La Vita Bella Day Spa LLC permission to perform the services scheduled, while holding La Vita Bella Day Spa LLC and its staff harmless to any adverse reactions.

Name of person:*

Name of minor:*

Consent:*

I request and consent to these procedures being carried out today without undergoing a sensitivity patch kit. 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. I also agree to notify La Vita Bella Day Spa with any questions or concerns I may have regarding today's appointment.

Your Signature:*

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La Vita Bella Day Spa
5416 Roberts Street
Shawnee, KS
clients@lavitabelladayspa.com
913-441-9090

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