lash extensions.
00. the basics
Name
*
First Name
Last Name
Email
example@example.com
01. health history
Do you wear contacts on a regular basis?
*
Yes
No
-please remove your contacts prior to your service if you are able to
Do you have any issues with medical adhesive tape?
*
Yes
No
Do you have a confirmed allergy to Acrylate/ Cyanoacrylate (bonding agent)?
*
No
Maybe, not confirmed
Yes
Please list all current medications that you are taking (including OTC, supplements, and vitamins):
Have you ever had any of these conditions?
Alopecia
Blepharitis
Back Pain/ Injury
Claustrophobia
Conjunctivitis/ Pink Eye
Diabetes
Dry Eye Syndrom
Eye Sites/ Sores
Herpes of the eye
Intense Stress
Light Sensitivity
Ocular Rosacea
Rosacea
Sensitive Eyes
Stroke
Thyroid Disease
Trichotillomania
Recent eye surgery
Current eye irritation
Current Conjunctivitis/ Pink Eye
Which side do you most often sleep on?
*
Right
Left
Back
Stomach
How fast do you feel your hair grows?
*
Fast
Slow
Normal
Is there anything else you think I should know?
02. informed consent
Although every precaution will be taken to ensure your safety and wellbeing before, during, and after your lash extension application, please be aware of the following information and possible risks. Please READ and SIGN stating you understand and agree to the following:
I understand that a full set of lash extensions can make the appearance of my own lashes about 30-50% thicker, and make my lashes appear 20-50% longer.
I understand that lash extension services have some inherent risk of irritation to the orbital eye area, including the eye itself, and could result in stinging and burning, blurry vision and potential blindness should the adhesive enter the eye or should an allergic reaction occur.
I understand that some irritation, itching, or burning may occur on the skin if the bonding agent comes into contact with it.
I understand that if the bonding agent comes into contact with my eye, my eye will be flushed with water and I will be assisted in seeking medical attention immediately.
I understand that this is a semi-permanent procedure, as my natural lashes will continue to grow and fall out normally, making touch- up or "fill" appointments necessary to maintain the original look achieved by replacing the lashes that have fallen out. Most clients require fill appointments every 2-3 weeks.
I understand that while every attempt will be made to provide me with the length and fullness I have chosen, my final result may not be what I initially envisioned.
I understand that it is imperative that I disclose all of the information requested in the Client Profile/ Health History
I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications.
I understand that additional conditions could occur or be discovered during the procedure which could affect my ability to tolerate the procedure.
I understand that if I have concerns, I will address these with my lash extension specialist. I give permission to my lash extensions specialist to perform the lash extensions procedure we have discussed and will hold him/her and his/her staff harmless and nameless from any liability that may result from this treatment. I have accurately answered the questions above, including all known allergies, prescription drugs, or products I am currently ingesting or using topically. I understand my lash extension specialist will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult the lash extension specialist immediately. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold Remedy Beauty Co. LLC responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today.
Signature
*
Today's Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: