Lash Extension Consent form

Lash Extension Consent form

Lash Extension Consent form

Please fill out the information below. If you have any questions please reach out to Raquel of Elevate Lash and Brow Studio LLC.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthday (mm/dd)
How did you find me?*

Internet SearchSocial MediaReferral - Let me know belowOther
Is this your first time receiving a lash procedure?*

YesNo
If no, please provide date, what you last had done and provider.
example: lash lift, classic lashes, volume lashes, or mega and the date of your last service.
Are you receiving a lash removal?*

NoYes
If yes, lash removal will have to be scheduled in addition to full set. There is not enough time in a full set appointment to do a removal. ** Please note that if there isn't enough time prior to scheduled full set, it is the responsibility of the client to reach out to Raquel to schedule a removal.
Removal of lash extensions applied at a foreign studio may expose visible breakage, gaps, thinning, and accumulated damage as a direct result of the original application technique. Raquel (of Elevate Lash and Brow Studio LLC) is not responsible for the condition of my lashes post removal.

I understand and acknowledge this policy
If yes, are you experiencing any of the following:

DiscomfortItching or burning sensationPulling or pinching sensationSwellingSkin irritation
Any Additional comments or concerns:
Lash Health
Please select any conditions or contraindications that apply:

Eye InfectionCorneal AbrasionCyanoacrylate AllergyGlaucomaThyroid ConditionCancerClaustrophobiaOCDTrichotillomaniaBack or neck painDry eyeExcessive TearingLight SensitivityLatex AllergySilicone AllergySkin DisordersBlepharitisHyper SensitivitiesRecent cosmetic/facial proceduresPregnantBreastfeedingSeasonal Allergies
Other relevant health related information:
Lifestyle
Do you wear contacts*

YesNo
Please select any that apply to your lifestyle"

Hot YogaFrequent SwimmingActive LifestyleSaunaFacials/Esthetic treatmentsCyclingHigh heat exposure
What side do you primarily sleep on?*

Left sideRight sidebackOn face
Skincare and Makeup

Skin exfoliantsSunscreenMoisturizerOil Facial CleanserSkin SerumMakeup RemoverEye CreamGel EyelinerPencil EyelinerEyeshadow PrimerEyeshadowMascaraFace PowdersMakeup Setting Mist
How often do you wear strip lashes?

NeverOccasionallyFrequently (2x a week)Very Frequently (3-5x a week)Daily
Have you used a lash growth serum in the lash 6 months?

YesNo
Do you have a tendency to pick or pull your lashes?

NoYes
Are you on a special diet?
Please be advised that low-carb, low-protein, and quick-result diets may affect a body's chemical balance which can lead to lackluster skin or loss of hair/natural eyelashes.
Your Service
What lash procedure are you receiving?

Classic Lash ExtensionsVolume Lash ExtensionsHybrid Lash ExtensionsStriplash/Mega Volume Lash Extensions
Please list any helpful details that will allow us to customize your experience.
Example: Preferences, expectations, style/fullness etc...
Consent

Please select YES if you agree and understand the information below.
I understand that if I sleep on my left side, right side or stomach, this can cause my lash extensions to fall off prematurely.*

yes
I understand that it is required to show up to appointment without makeup on or around eye. Arriving with makeup can affect the retention of the Lash Extensions and result in the appointment to be canceled. If appointment cancelation is needed you will be responsible for 100% of the service. (Under eye canceler and foundation (away from the eye) are okay, but please be advised that washing the under eye area may be needed).*

yes
I understand that it is required to reframe from wearing false lashes 5 days before service. False lash glue can stick to the lash line and prevent Lash Extension from sticking on the natural lashes. If there is false lash glue stuck on the natural lashes the appointment will be canceled. If appointment cancelation is needed you will be responsible for 100% of the service.*

yes
I understand that during the Lash Extension treatment that my eyes must remain closed for the entire duration of the appointment time. (Appointment time can take 2-4 hours. Time differs from service type: Classic, Hybrid, Volume...)*

yes
I understand that maintenance on Lash Extensions should be every 2-3 weeks. If client have less than 50% remaining they will need to also book for an extended fill to ensure your service provider has enough time to complete your fill. Any fill booked 4 weeks or later from their last visit will be charged for a full set.*

yes
I understand that the intensity/length of the Lash Extensions set is determined by the integrity and length of the natural lashes.*

yes
I understand that if I fail to follow the aftercare instructions that will lessen the longevity of the Lash Extensions and can jeopardize the health of my natural lash.*

yes
I understand that lash extension adhesive has some inherent risk of irritation to the orbital eye area, including the itself, and could result in stinging or burning, blurry vision and potential blindness.*

yes
I understand that if I change my current skin care routine or begin a new medication that may effect the skin/hair, that I will inform my lash artist before my next appointment.*

yes
I release the rights to any photos taken before, during, or after the procedure to be used for educational or marketing purposes.*

yesno
Salon Policies

Please read carefully and initial below that you understand all Salon Policies.
Cancelation Policy: Appointments must be cancelled at least 48hrs before your appointment. If you cancel less than 48hrs in advance you will be charged 50% of the service amount. This includes switching appointments the day of service or canceling the day of appointment to reschedule for an alternative day within the week(s). Any change in appointment must be made sooner than 48 hours. There are no exceptions to the cancellation policy (Example: Covid, emergencies, being sick). After 2nd Late Cancelation you will be responsible for 100% of the service fee. Excessive cancellations and rescheduling may result in Non-refundable deposit or no longer being accepted as a client. No Shows will be charged 100% of the service. By booking an appointment + providing a credit card on file in your account (on Square) you are authorizing to change the card for file in the event of a No Show. *
Please initial above if you understand Cancelation Policy
Late to Appointment Policy: As a courtesy, each client is given a 10-minute grace period to arrive. In the case of late arrival, within the 10-minute grace period, the time will be taken out of your service. No additional time will be added to your appointment. If you are more than 10 minutes late I have the right to cancel your appointment and you will be charged 50% of the scheduled service.Excessive late appointments may result in me no longer taking you as a client. Please respect that this is an appointment based service, and 1 late client can throw off the rest of the day.*
Please initial above if you understand Late to Appointment Policy
Covid/Sick Policy: If you or anyone in your household has Covid you are responsible to cancel/reschedule your appointment accordingly. In the event you show up to your appointment sick or its brought to my attention that you came to an appointment sick, you will no longer be accepted as a client. If you show up to your appointment sick you will be asked to leave and will be responsible for the Late Cancelation fee. There will be no exceptions. *
Please initial above if you understand Covid/Sick Policy
Account Balance Policy: In the event the card on file is not accepted for a late cancellation or NO SHOW appointment than an account balance will occur. We require that all clients pay their account balance to zero (0) prior to receiving further services.*
Please initial above if you understand Account Balance Policy
No Guest/Children Policy: No additional guest will be allowed at appointment.I am sorry but please leave children/guests at home as it’s a safety hazard/liability concern. Depending on the service you will have your eyes closed for up to 1-4 hrs*
Please initial above if you understand No Guest Policy
Pre-Service Instructions and Aftercare Policy: Please review the service protocols on my website pertaining to your service. There are pre service instructions to make sure we get the most out of our service time. It’s also very important to properly take care of your lashes. If you are not following proper aftercare it may result in me no longer taking you as a client.*
Please initial above if you understand Late Policy
Refunds/Corrections Policy: There are no refunds on all services. If there is an issue with your lashes you MUST contact me within 48hrs. If you contact me within the 48hrs we can find a time to get you in for a complimentary correction. Unfortunately, if you don’t let me know within 48hrs you will need to schedule for a normal fill.*
Please initial above if you understand Refund/Correction Policy
By signing below I acknowledge that I have read and agree to all policies and information above. If I have any concerns, I will address these to Raquel (of Elevate Lash and Brow Studio LLC). I give permission to the Raquel (of Elevate Lash and Brow Studio LLC) to perform scheduled service(s), and will hold her harmless from any liability that may result in 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 esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I have additional questions or concerns regrading treatment, I will consult with Raquel (of Elevate Lash and Brow Studio LLC) 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 procedure and accept the risk. I do not hold Raquel (of Elevate Lash and Brow Studio 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 preformed on scheduled appointment date(s).
Signature*
Date*

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Date
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