Client Consent Form

Name*
First Last
Address*
Street Address City State ZIP Code
Phone*
Email*
Appointment Date
MM slash DD slash YYYY
How did you hear about us?*
- Friend
- Google/web search
- Facebook/Instagram
- Website
- Other
What's your friend's name?
Is this the first time you've had eyelash extensions applied?*
- Yes
- No
Where have you had them applied?
What was the approximate date?
Are you having lash extensions applied for a special occasion or daily wear?*
- Special Occasion
- Daily Wear
Do you wear contacts?*
- Yes
- No
Do you habitually rub, pull, or pick your lashes?*
- Yes
- No
Do you have, or are you being treated for, any eye illness or injury?*
- Yes
- No
Please list any eye drops or eye medication you are using:
What side do you predominantly sleep on?*
- Right
- Left
- Neither
Are you able to keep your eyes closed and lie still for 2 hours or longer?*
- Yes
- No
Please check any of the following that apply to you:*
- Select All
- Permanent eye make-up
- Use of retinoid for skin treatment
- Blepharoplasty within last 6 months
- Chemotherapy within last 6 months
- Lasik Eye Surgery within last 120 days
- Severe stress
- Allergies to glycerin
- Hormonal imbalance
- Allergies to adhesive or synthetics
- Recent high fever or severe illness
- Other
Please describe:
CONSENT FOR EYELASH PROCEDURE
I have agreed to have eyelash extensions applied to and/or removed from my natural eyelashes. Before my licensed eyelash professional can perform this procedure, I understand I must complete this agreement and provide my informed consent by signing and dating where indicated below.
1. Waiver of Liability. I understand there are risks associated with having artificial eyelash extensions applied to and/or removed from my natural eyelashes, and that notwithstanding the utmost of care in the application or removal of these products, there still exists risks associated with the procedure and product itself, which include, without limitation, eye irritation, eye pain, discomfort, and, in rare cases blindness when improperly handled. As part of this procedure, I understand that a certain amount of eyelash adhesive material will be used to attach artificial eyelashes to my natural eyelashes. Even though the eyelash extension professional may apply or remove the artificial eyelashes properly, I understand adhesive material may become dislodged during or after the procedure, which may irritate my eyes or require follow-up care, at my own expense to prevent damage to my eyes. I also agree to defend, indemnify and hold harmless my service provider from any and all claims, actions, expenses, damages and liabilities, including reasonable attorneys’ fees which might be asserted against them as a result of my having this procedure performed.
2. Permission to Use Pictures. I hereby grant my service provider the full right to take, publish and reproduce photographs of me, my face, my eyes and/or eyelashes, both before and after the procedure, for any advertising, education, or other purposes whatsoever, including the right to retouch these photographs as deemed necessary. I further expressly assign any copyright in these photographs. I also grant consent to use my images and likeness as contained in these photographs, along with any comments I may provide.
3. Care and Maintenance. I agree to follow the care and maintenance instructions provided to me for the use and care of my eyelash extensions, and that if any follow up care is required due to my own mistake or negligence, or failure to follow these instructions, this will be at my own expense and risk. I understand that if I do any of the following, it may result in damage to my eyelash extensions or my cause my lashes to fall o" prematurely. Knowing this I agree to follow these instructions for best results: I will avoid oil based eye products as these will loosen the bond of my eyelash extensions. I will avoid getting my lashes wet within 24 hours after application. For the first two days after application, I understand it is best to avoid swimming, saunas or steam rooms. If I experience any itching or irritation, I agree to contact my service provider immediately to have the lash extensions removed. I agree to avoid using waterproof mascara and to not use an eyelash curler, perm, or tint on my eyelash extensions. I agree not to pick, pull or rub my eyelash extensions. I understand that I should not attempt to remove my eyelash extensions on my own or with any product, but that the procedure requires that my eyelash extensions be professionally removed.
4. No Know Medical Conditions / Informed Consent. I have read and completed the Client Intake Form in its entirety and in truth. I acknowledge that I have been advised of the potentially harmful or negative side effects that the eyelash extension procedure or removal may cause to those who have specific medical or skin conditions. I understand that the adhesives and adhesive remover are a skin, eye and mucus membrane irritant and that in rare cases persons may be allergic or have hypersensitivity to synthetics, cyanoacrylate or formaldehyde which in small amounts may be present in the adhesive. I understand that the procedure requires that I lay still for up to 3 hours or longer with my eyes closed, and that if I wear contacts, I must remove my contact lenses for the duration of the lash extension application or removal. I further state that I have no known medical condition that might be aggravated by the procedure or any medical condition that would prevent me from complying with or heeding to instructions or these warnings.
If any action is brought to enforce the terms of this Agreement, the prevailing party shall be entitled to its costs and reasonable attorneys’ fees. Any claims arising out of this agreement will be resolved through the binding arbitration using the rules of the American Arbitration Association.
This Agreement will remain in effect for this procedure, and all future procedures.
I agree that this Agreement is binding upon me, and my heirs, legal representatives and assigns. I represent that I am at least 18 years of age and that I have the right to enter this agreement, or if I am under 18 years of age, I have my parent or legal guardians consent to this agreement and his or her relationship to me is as follows: ___________________________. By his or her signature below, he or she ratifies and consents to this procedure under these terms.
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Signature
Name
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Date
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Parent/Guardian Signature
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Date
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Licensed Lash/Brow Artist Signature
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Date
MM slash DD slash YYYY
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