Please fill out and submit the Consultation Form below which enables us to treat you.

* - Required Field.

First Name*
Last Name*
Email Address*
A sensitivity patch test is offered and to be done minimum 48 hours ahead of the treatment appointment, you can choose to waiver the patch test and therefore release the therapist from liability.
I understand It is not recommended to waiver a patch test if you have a history of severe allergies or a history of anaphylaxis. *

I confirm that it is my responsibility to ask sufficient information about the treatment and product on the day of my appointment prior to the treatment. I understand the importance of my accurate and complete medical history and that withholding any medical conditions may be detrimental to my health and the outcome of the procedure.
I have not had any eye infections within the last 4 weeks. I understand that there are no guarantees as to the success of my treatment and I will not hold the therapist liable.
I understand that in some cases the lashes may not lift or may lift more or than my desired expectation.
Post treatment: Keep treated area dry for 24hours. Avoid manipulation of the treated area.
I understand that I must adhere to the aftercare advice. I hereby give consent to carry out the treatment of my choice.
I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment.
I further agree in the event of non-payment, to bear the cost of collection, and/or Court cost and reasonable legal fees, should this be required.
By accepting, I acknowledge that I have read the foregoing informed consent and agree to the treatment with its associated risks.
I hereby give consent to perform this and all subsequent treatments with the above understood.
I hereby release the practitioner from liability associated with this procedure.
I hold her free from any claims, suits or damages for any injury or complications resulting from this treatment.
I confirm that I accept all liability. *
Sign Your Name*