Indemnity Form/Client Confidentially form

First Name *

Last Name *

Salon Name *

Gender *

Male

Female

Date of birth *

Phone *

Email *

Address *

City *

State *

Postal code *

Any Medications? *

Other relevant information

Have you had lash or brow tinting, Lash perming, Eyelash extension or semi-permanent mascara applied previously? *

Yes

No

Additional information

AGREEEMENT: 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.

Signature *

Clear