Elleebana Lash Lift Consent Elleebana Lash Lift Consent Name* First Last Email:* Date of Birth* MM DD YYYY Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country I authorize Plumberry Skin Care Theresa Toth lash professional to perform the Elleebana Lash Lift procedure. I understand that the lashes will be curled with an advanced solution and a conditioning cream. I understand it is my responsibility to be still during the procedure and to keep my eyes closed during the process unless otherwise advised. I understand that in some cases there may be complications such as eye redness, irritation and allergic reaction to the products used to lift the lashes and understand the risk of the cosmetic treatment I have chosen. I understand that if at any time I ( or the esthetician) are uncomfortable with the Lash Lift treatment, I will inform the esthetician and she will gladly rectify the problem, including ending the session. I understand there are no guarantees, warranties, promises, commitments or refunds and acknowledge that I have no particular representation or guarantees, and I am consenting to the Elleebana Lash Lift at my own risk. I understand that all conditions must be revealed or disclosed by me to my esthetician regarding health history, medications being taken and any past reactions to products used. I herein signed, release, give up, acquit and discharge Plumberry Skin Care Theresa Toth lash professional and or anyone affiliated there to including any partnership, corporations or company associated with said individual from any claims or damages of any nature. I have read all information provided:* Please sign and date below to indicate that you have read all statements and understand: I, the client herein signed, certify that I have read and had explained to me and fully understand the above waiver and release form. I have provided information regarding my health and medications taken to the best of my knowledge, the client herein signed, for the purposed of documentation, hereby consent to any “before and after” photographs, which may or may not be used for the purposes of advertising. Date* MM DD YYYY Signature*EmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle AJAX powered Gravity Forms.