Lash Lift and Tint New Client Form

These guidelines are in place for your protection and ours, as we strive to serve you to the best of our ability.

Please arrive at least 15 minutes early for your first appointment.

Please understand the importance of keeping your appointments. We do have a 48 hour new client/24 hour regular client appointment cancellation policy that is strictly enforced.

Please contact us if you have any questions or need additional information.

Please enable JavaScript in your browser to complete this form.

AUTHORIZATION FOR USE OR DISCLOSURE OF PATIENT PHOTOGRAPHIC AND/OR VIDEO IMAGES

AUTHORIZATION:

I authorize the use and disclosure of my name, photographic/video images, and/or testimonial for marketing purposes by the practice listed below. I understand that information disclosed pursuant to this authorization may be subject to redisclosure and may no longer be protected by HIPAA privacy regulations.

PURPOSE:
The photographic/video images, and/or testimonial will be used for: Social Media and/or Advertising

REVOCABILITY:
I understand that I may revoke this authorization at any time, but such revocation must be in writing and received by the practice via registered mail. Revocation affects disclosure moving forward and is not retroactive. This authorization expires 99 years from the date signed.

NO TREATMENT CONDITIONS:
I understand that the practice cannot condition treatment on whether or not I sign this authorization.

IF DESIRED, COPY PROVIDED:

“Yes, I would like a copy of this form.”

Date:

Name:

IF PERSONAL REPRESENTATIVE:

Representative's Name:

Relationship to patient:

IF PATIENT IS A MINOR:

Patient/Guardian Name:

This form is provided by The Well of Life Center for Natural Health, LLC for general convenience purposes and does not represent legal advice. Additional compliance rules vary from state to state, country to country. If you feel like you need legal consultation in addition to what we’ve provided, be sure to consult your practice attorney including seeking advice pertaining to HIPAA compliance, the HITECH Act, and the U.S. Department of Health and Human Services regulations. We are NOT attorneys, and although this form is based on our own research to ensure compliance, it does not represent legal advice.

Electronic Signature: *

Sign by typing your full name in the box above. By signing, you are acknowledging that you have read and accept the terms and conditions of the above Authorization For Use Or Disclosure Of Patient Photographic and/or Video Images.

CLIENT INFORMATION:

Name: *

Today's Date: *

Home Phone Number:

Cell Phone Number: *

Email: *

Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Birthdate: *

Age: *

Gender: *

Are you currently a client of The Well of Life Center? *

If yes, who is your Clinician?

In Case of Emergency, please contact:

Emergency Contact Name: *

Emergency Contact Phone Number: *

Relationship: *

Health & History Questionnaire

Previous discomfort, stinging and adverse reactions please check:

Skin Disorders
Inflammation of the skin
Eye disease
Eye Infections
Recent eye surgery
Blephartitis
Watery eyes
Hayfever
Allergies
Bell’s Palsy
Previous reactions to eye treatments
Contact lenses
Allergies to latex/band aids
Allergies to adhesives, glues or bonding agents
Allergies to acetone
Are you pregnant or lactating?
Skin Disorders
Are you taking HRT?

List any medications:

Other relevant information:

Have you had eyelash or brow tinting, eyelash perming, eyelash extensions or semi-permanent mascara applied previously? *

If yes, which treatment(s)?

Tinting
Eyelash Perm/Lift
Eyelash Extensions
Semi-permanent mascara

Did you experience any reaction to these treatments? *

If yes, which treatment(s)?

Tinting
Eyelash Perm/Lift
Eyelash Extensions
Semi-permanent mascara

If yes, when?

Please provide details of any reactions:

Did you seek medical advice from a doctor or specialist as a result of this reaction? *

What was the advice of your doctor/treatment given:

What treatment will you be receiving?

Agreement: 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).

Liability Release Form and Agreement and Release of Liability: *

Please click HERE to read our Policies and Liability Release Form and Agreement and Release of Liability. Then, sign by typing your full name in the box above. By signing, you are acknowledging that you have read and accept the terms and conditions of the Spa Policies and Liability Release Form and Agreement and Release of Liability.

Website

Location

203 Farm Lane
Doylestown, PA 18901

Spa Hours

Mon. 9am – 7pm
Tues. 10am – 7pm
Wed. and Thurs. 9am – 7pm
Fri. 9am – 3pm
Sat. 8am – 12pm