{"id":271465,"date":"2024-02-23T20:28:35","date_gmt":"2024-02-23T20:28:35","guid":{"rendered":"https:\/\/lavidamassagefortcollinsco.com\/?page_id=271465"},"modified":"2024-06-21T18:34:44","modified_gmt":"2024-06-21T18:34:44","slug":"lash-brow-intake-form","status":"publish","type":"page","link":"https:\/\/lavidamassagefortcollinsco.com\/forms\/lash-brow-intake-form\/","title":{"rendered":"Lash and Brow Intake Form"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; admin_label=&#8221;section&#8221; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_row admin_label=&#8221;row&#8221; _builder_version=&#8221;4.16&#8243; background_size=&#8221;initial&#8221; background_position=&#8221;top_left&#8221; background_repeat=&#8221;repeat&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.16&#8243; custom_padding=&#8221;|||&#8221; global_colors_info=&#8221;{}&#8221; custom_padding__hover=&#8221;|||&#8221;][et_pb_text admin_label=&#8221;Text&#8221; _builder_version=&#8221;4.25.1&#8243; background_size=&#8221;initial&#8221; background_position=&#8221;top_left&#8221; background_repeat=&#8221;repeat&#8221; custom_margin=&#8221;|0px||0px|false|false&#8221; custom_padding=&#8221;|0px||0px|false|false&#8221; hover_enabled=&#8221;0&#8243; global_colors_info=&#8221;{}&#8221; sticky_enabled=&#8221;0&#8243;]<\/p>\n<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_9' ><div id='gf_9' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Lash and Brow Services Intake Form<\/h2>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_9' id='gform_9'  action='\/wp-json\/wp\/v2\/pages\/271465#gf_9' data-formid='9' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_9' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_9_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_1\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_9_1'>\n                            \n                            <span id='input_9_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_9_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_9_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_9_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_9_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_9_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_9_3\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_3\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I am informing my technician of any of the following contraindicated conditions for the Lash Lift and Tinted<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_9_3'><div class='gchoice gchoice_9_3_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.1' type='checkbox'  value='Allergies to adhesives tape, fumes, or lash pads'  id='choice_9_3_1'   aria-describedby=\"gfield_description_9_3\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_9_3_1' id='label_9_3_1' class='gform-field-label gform-field-label--type-inline'>Allergies to adhesives tape, fumes, or lash pads<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_3_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.2' type='checkbox'  value='Sensitive or allergic to lash tint, or tint developer'  id='choice_9_3_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_3_2' id='label_9_3_2' class='gform-field-label gform-field-label--type-inline'>Sensitive or allergic to lash tint, or tint developer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_3_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.3' type='checkbox'  value='Sensitive or allergic to makeup remover, lash cleanser, or eyewash'  id='choice_9_3_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_3_3' id='label_9_3_3' class='gform-field-label gform-field-label--type-inline'>Sensitive or allergic to makeup remover, lash cleanser, or eyewash<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_3_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.4' type='checkbox'  value='Rosacea'  id='choice_9_3_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_3_4' id='label_9_3_4' class='gform-field-label gform-field-label--type-inline'>Rosacea<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_3_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.5' type='checkbox'  value='Currently undergoing Chemo\/ radiation treatments'  id='choice_9_3_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_3_5' id='label_9_3_5' class='gform-field-label gform-field-label--type-inline'>Currently undergoing Chemo\/ radiation treatments<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_3_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.6' type='checkbox'  value='Dry eye syndrome'  id='choice_9_3_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_3_6' id='label_9_3_6' class='gform-field-label gform-field-label--type-inline'>Dry eye syndrome<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_9_3'>\nCheck any that apply<\/div><\/fieldset><div id=\"field_9_4\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_4\" ><label class='gfield_label gform-field-label' for='input_9_4'>Please list any other contraindicators\/skin conditions:<\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_9_4' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_9_5\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_5\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I am informing my technician of any of the following contraindicated conditions for the Brow Lamination and Brow Shaping\/Waxing<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_9_5'><div class='gchoice gchoice_9_5_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.1' type='checkbox'  value='Currently undergoing Chemo\/ radiation treatments'  id='choice_9_5_1'   aria-describedby=\"gfield_description_9_5\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_9_5_1' id='label_9_5_1' class='gform-field-label gform-field-label--type-inline'>Currently undergoing Chemo\/ radiation treatments<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_5_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.2' type='checkbox'  value='Rosacea'  id='choice_9_5_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_5_2' id='label_9_5_2' class='gform-field-label gform-field-label--type-inline'>Rosacea<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_5_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.3' type='checkbox'  value='Eczema'  id='choice_9_5_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_5_3' id='label_9_5_3' class='gform-field-label gform-field-label--type-inline'>Eczema<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_5_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.4' type='checkbox'  value='Alopecia'  id='choice_9_5_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_5_4' id='label_9_5_4' class='gform-field-label gform-field-label--type-inline'>Alopecia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_5_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.5' type='checkbox'  value='Sun Burn'  id='choice_9_5_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_5_5' id='label_9_5_5' class='gform-field-label gform-field-label--type-inline'>Sun Burn<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_5_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.6' type='checkbox'  value='Ultra-Sensitive Skin'  id='choice_9_5_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_5_6' id='label_9_5_6' class='gform-field-label gform-field-label--type-inline'>Ultra-Sensitive Skin<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_5_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.7' type='checkbox'  value='Wounds in treatment area'  id='choice_9_5_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_5_7' id='label_9_5_7' class='gform-field-label gform-field-label--type-inline'>Wounds in treatment area<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_5_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.8' type='checkbox'  value='Sensitive or allergic to wax or latex'  id='choice_9_5_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_5_8' id='label_9_5_8' class='gform-field-label gform-field-label--type-inline'>Sensitive or allergic to wax or latex<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_9_5'>Check any that apply<\/div><\/fieldset><div id=\"field_9_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_6\" ><label class='gfield_label gform-field-label' for='input_9_6'>Please list any other contraindicators\/skin conditions<\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_9_6' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_9_7\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_7\" ><legend class='gfield_label gform-field-label' >I consent to having my eyes closed and covered for the duration of the 45\u201390-minute procedure<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_7'>\n\t\t\t<div class='gchoice gchoice_9_7_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='Yes'  id='choice_9_7_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_7_0' id='label_9_7_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_7_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='No'  id='choice_9_7_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_7_1' id='label_9_7_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_8\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_8\" ><legend class='gfield_label gform-field-label' >I wear contacts<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_8'>\n\t\t\t<div class='gchoice gchoice_9_8_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Yes'  id='choice_9_8_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_8_0' id='label_9_8_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_8_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='No'  id='choice_9_8_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_8_1' id='label_9_8_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_11\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_11\" ><b>I agree to have an eyelash lift, brow lamination and\/or eyelash tint applied to my natural eyelashes and\/or retouched.<\/b> By signing this agreement, I consent to the procedure of an eyelash perm, brow lamination or eyelash tint or wax\/shaping by my technician. I understand there are risks associated with having an eyelash perm, brow lamination and\/or eyelash tint or waxing. I further understand that as part of the procedure, eye irritation, eye pain, eye itching, discomfort, and in rare cases eye infection or blurriness could occur. I understand that some mild but normal symptoms may occur with the brow lamination depending on the sensitivity of my skin during the procedure and will\nsubside in 24 hours. These symptoms may include mild tingling, slight redness due to brushing the hairs, slight warmth in the area. I agree that if I experience any of these medical conditions with my lashes that I will contact my technician and consult a physician at my own expense. I understand that even though my technician perms the\nlashes\/brows using the proper technique, the instruments, wax, tapes, cleaners, eye gel pads, adhesives, and removers used may irritate my eyes\/brows or require a\nphysician\u2019s follow-up care. I understand and agree to the care instructions provided by my technician for the use and care of my permed and\/or tinted eyelashes\/eyebrows. I realize and accept the consequences of failure to adhere to these instructions may cause the eyelashes to not stay permed if told. \n\n<p><b>I agree to the following Post- Lash Lift:<\/b> No water can meet the eye area for 24 hours after the application. Avoid makeup such as mascara, eyeliner, or brow pencil for the first 24 hours. Avoid using oil containing sunscreens, moisturizers, and cleansers on lashes for the first 24 hours. \n\n<p><b>Acknowledgement and Waiver I am over 18 years of age and consent to the agreement and to treatment or have a parent with me that consents to this service.<\/b> This agreement will remain in effect for this procedure and all future procedures conducted by my technician. I read English and understand that this consent agreement is legal and binding. I have read and fully understand all information in this agreement. I release my technician from all liability associated with this procedure, which is performed with the utmost attention to safety and proper application using tools and products that the technician has been professionally trained to use. There are no guarantees for length of time the lashes will stay permed. I understand the aftercare instructions and will do my part to maintain my eyelashes. I understand that there are many factors that may affect the life of the eyelash lift such as water and\nmoisture contact, weather conditions, and activities involving exposure to high temperatures. \n\n<p>By signing below, I verify that I have read and understand the above statements and agree to them.<\/div><div id=\"field_9_10\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_10\" ><label class='gfield_label gform-field-label' for='input_9_10'>Signature<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_9_10_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_9_10_valid' id='input_9_10_valid' \/><canvas id='input_9_10' width='300' 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*\/\n<\/script>\n\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"\n                <div class='gf_browser_unknown gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_9' ><div id='gf_9' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Lash and Brow Services Intake Form<\/h2>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_9' id='gform_9'  action='\/wp-json\/wp\/v2\/pages\/271465#gf_9' data-formid='9' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_9' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_9_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_1\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_9_1'>\n                            \n                            <span id='input_9_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_9_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_9_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_9_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_9_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_9_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_9_3\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_3\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I am informing my technician of any of the following contraindicated conditions for the Lash Lift and Tinted<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_9_3'><div class='gchoice gchoice_9_3_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.1' type='checkbox'  value='Allergies to adhesives tape, fumes, or lash pads'  id='choice_9_3_1'   aria-describedby=\"gfield_description_9_3\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_9_3_1' id='label_9_3_1' class='gform-field-label gform-field-label--type-inline'>Allergies to adhesives tape, fumes, or lash pads<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_3_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.2' type='checkbox'  value='Sensitive or allergic to lash tint, or tint developer'  id='choice_9_3_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_3_2' id='label_9_3_2' class='gform-field-label gform-field-label--type-inline'>Sensitive or allergic to lash tint, or tint developer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_3_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.3' type='checkbox'  value='Sensitive or allergic to makeup remover, lash cleanser, or eyewash'  id='choice_9_3_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_3_3' id='label_9_3_3' class='gform-field-label gform-field-label--type-inline'>Sensitive or allergic to makeup remover, lash cleanser, or eyewash<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_3_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.4' type='checkbox'  value='Rosacea'  id='choice_9_3_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_3_4' id='label_9_3_4' class='gform-field-label gform-field-label--type-inline'>Rosacea<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_3_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.5' type='checkbox'  value='Currently undergoing Chemo\/ radiation treatments'  id='choice_9_3_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_3_5' id='label_9_3_5' class='gform-field-label gform-field-label--type-inline'>Currently undergoing Chemo\/ radiation treatments<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_3_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.6' type='checkbox'  value='Dry eye syndrome'  id='choice_9_3_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_3_6' id='label_9_3_6' class='gform-field-label gform-field-label--type-inline'>Dry eye syndrome<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_9_3'>\nCheck any that apply<\/div><\/fieldset><div id=\"field_9_4\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_4\" ><label class='gfield_label gform-field-label' for='input_9_4'>Please list any other contraindicators\/skin conditions:<\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_9_4' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_9_5\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_5\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I am informing my technician of any of the following contraindicated conditions for the Brow Lamination and Brow Shaping\/Waxing<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_9_5'><div class='gchoice gchoice_9_5_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.1' type='checkbox'  value='Currently undergoing Chemo\/ radiation treatments'  id='choice_9_5_1'   aria-describedby=\"gfield_description_9_5\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_9_5_1' id='label_9_5_1' class='gform-field-label gform-field-label--type-inline'>Currently undergoing Chemo\/ radiation treatments<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_5_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.2' type='checkbox'  value='Rosacea'  id='choice_9_5_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_5_2' id='label_9_5_2' class='gform-field-label gform-field-label--type-inline'>Rosacea<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_5_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.3' type='checkbox'  value='Eczema'  id='choice_9_5_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_5_3' id='label_9_5_3' class='gform-field-label gform-field-label--type-inline'>Eczema<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_5_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.4' type='checkbox'  value='Alopecia'  id='choice_9_5_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_5_4' id='label_9_5_4' class='gform-field-label gform-field-label--type-inline'>Alopecia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_5_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.5' type='checkbox'  value='Sun Burn'  id='choice_9_5_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_5_5' id='label_9_5_5' class='gform-field-label gform-field-label--type-inline'>Sun Burn<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_5_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.6' type='checkbox'  value='Ultra-Sensitive Skin'  id='choice_9_5_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_5_6' id='label_9_5_6' class='gform-field-label gform-field-label--type-inline'>Ultra-Sensitive Skin<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_5_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.7' type='checkbox'  value='Wounds in treatment area'  id='choice_9_5_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_5_7' id='label_9_5_7' class='gform-field-label gform-field-label--type-inline'>Wounds in treatment area<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_5_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.8' type='checkbox'  value='Sensitive or allergic to wax or latex'  id='choice_9_5_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_5_8' id='label_9_5_8' class='gform-field-label gform-field-label--type-inline'>Sensitive or allergic to wax or latex<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_9_5'>Check any that apply<\/div><\/fieldset><div id=\"field_9_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_6\" ><label class='gfield_label gform-field-label' for='input_9_6'>Please list any other contraindicators\/skin conditions<\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_9_6' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_9_7\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_7\" ><legend class='gfield_label gform-field-label' >I consent to having my eyes closed and covered for the duration of the 45\u201390-minute procedure<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_7'>\n\t\t\t<div class='gchoice gchoice_9_7_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='Yes'  id='choice_9_7_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_7_0' id='label_9_7_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_7_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='No'  id='choice_9_7_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_7_1' id='label_9_7_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_8\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_8\" ><legend class='gfield_label gform-field-label' >I wear contacts<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_8'>\n\t\t\t<div class='gchoice gchoice_9_8_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Yes'  id='choice_9_8_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_8_0' id='label_9_8_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_8_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='No'  id='choice_9_8_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_8_1' id='label_9_8_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_11\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_11\" ><b>I agree to have an eyelash lift, brow lamination and\/or eyelash tint applied to my natural eyelashes and\/or retouched.<\/b> By signing this agreement, I consent to the procedure of an eyelash perm, brow lamination or eyelash tint or wax\/shaping by my technician. I understand there are risks associated with having an eyelash perm, brow lamination and\/or eyelash tint or waxing. I further understand that as part of the procedure, eye irritation, eye pain, eye itching, discomfort, and in rare cases eye infection or blurriness could occur. I understand that some mild but normal symptoms may occur with the brow lamination depending on the sensitivity of my skin during the procedure and will\nsubside in 24 hours. These symptoms may include mild tingling, slight redness due to brushing the hairs, slight warmth in the area. I agree that if I experience any of these medical conditions with my lashes that I will contact my technician and consult a physician at my own expense. I understand that even though my technician perms the\nlashes\/brows using the proper technique, the instruments, wax, tapes, cleaners, eye gel pads, adhesives, and removers used may irritate my eyes\/brows or require a\nphysician\u2019s follow-up care. I understand and agree to the care instructions provided by my technician for the use and care of my permed and\/or tinted eyelashes\/eyebrows. I realize and accept the consequences of failure to adhere to these instructions may cause the eyelashes to not stay permed if told. \n\n<p><b>I agree to the following Post- Lash Lift:<\/b> No water can meet the eye area for 24 hours after the application. Avoid makeup such as mascara, eyeliner, or brow pencil for the first 24 hours. Avoid using oil containing sunscreens, moisturizers, and cleansers on lashes for the first 24 hours. \n\n<p><b>Acknowledgement and Waiver I am over 18 years of age and consent to the agreement and to treatment or have a parent with me that consents to this service.<\/b> This agreement will remain in effect for this procedure and all future procedures conducted by my technician. I read English and understand that this consent agreement is legal and binding. I have read and fully understand all information in this agreement. I release my technician from all liability associated with this procedure, which is performed with the utmost attention to safety and proper application using tools and products that the technician has been professionally trained to use. There are no guarantees for length of time the lashes will stay permed. I understand the aftercare instructions and will do my part to maintain my eyelashes. I understand that there are many factors that may affect the life of the eyelash lift such as water and\nmoisture contact, weather conditions, and activities involving exposure to high temperatures. \n\n<p>By signing below, I verify that I have read and understand the above statements and agree to them.<\/div><div id=\"field_9_10\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_10\" ><label class='gfield_label gform-field-label' for='input_9_10'>Signature<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_9_10_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_9_10_valid' id='input_9_10_valid' \/><canvas id='input_9_10' width='300' 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