Eyelash extension consent
PLEASE ONLY COMPLETE THIS FORM IF YOU HAVE ALREADY BOOKED A PATCH TEST. To book you can call or text 07960566422 or use the chat section on my website ***Patch testing a minimum of 48hrs before your appointment is mandatory for the application of eyelash extensions, your appointment CAN NOT go ahead without one***. Please do not ask for lashes to be applied without having a patch test a this request will be declined, this is a legal requirement for insurance purposes and to keep you safe against having a major reaction. Please complete all details in full
Email
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example@example.com
Date of arranged patch test (please contact 07960566422 to arrange, appointment can not go ahead without one)
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Where did you hear about us?
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Personal recommendation
Website
Facebook
Instagram
Doctors surgery advertising board
Other
Personal Details
ONLY COMPLETE THIS FORM YOU HAVE ALREADY BOOKED A PATCH TEST. TO BOOK CALL OR MESSAGE ME ON 07960566422 *please complete all required fields*
Name
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First Name
Last Name
Phone Number
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Area Code
Phone Number
Date of birth
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Conditions/medical details
the following details will determine that you are suitable for eyelash extensions, please answer yes or no to each question
1. Have you ever had an allergic reaction to adhesives? This could include glues, tapes, band aids etc?
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yes
no
2. Have you had chemotherapy in the last 3 months? *medication used for chemotherapy may cause a reaction to materials used for eyelash extensions*
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yes
no
3.Are you taking any thyroid medications? *lashes may not last due to the medication in your system*
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Yes
no
4. Have you had any lasik surgery in the last 4 months? *you must wait 4months post-op for medical consent*
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yes
no
5. Have you had a blepharoplasty? *you must wait 6 months post-op for medical consent*
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yes
no
6. Do you wear contact lenses? *these must be removed prior to lashes being applied*
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yes
no
7. Do you have oily skin and hair? *oils can break down the bond of the adhesive used causing extensions to not last as long*
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yes
no
8. Are you taking any prescribed medication at present?
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Yes
no
If answered yes, please list below
9. Are you prone to allergic reactions, or ever had sensitivity to products
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yes
no
If yes, please list below
10. Do you have any skin conditions or lack of sensation in the eye area? For example swelling, infections, eczema.
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yes
no
11. Do you suffer from epilepsy or any condition causing fits or seizures?
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yes
no
12. Do you have any of the following eye disorders? Sty's, blepharitis, conjunctivitis, diabetic retinopathy, cysts in the eye area, cataract, dry eye, glaucoma, eyelid surgery or hay fever?
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yes
no
If answered yes, please list below
12. Are you pregnant?
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Yes
No
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I agree to the following:
please check each one to confirm you agree and unstand
I understand there are risks associated with having eyelash extensions applied to and/or removed from my natural lashes.
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I agree
I understand that the eyelash extensions will be applied to the natural lash as determined by my lash tech so as not to create excessive weight to the natural lash thereby preserving the health, growth and natural look of my lashes
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I agree
I understand as part of the procedure eye irritation, pain, itching and discomfort and in rare cases eye infection may occur
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I agree
I understand and agree that if I experience any of the above issues with my lashes I will contact my technician to inform them and consult my GP at my own expense.
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I agree
I understand then eventhough my technician may apply and remove the eyelashes properly, that adhesive materials may become dislodged during or after the procedure, which may irritate my eyes or require a further follow up.
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I agree
I agree to follow the aftercare instructions that will be given to me at the end of my first appointment. I also understand that failure to do so could result in the extensions falling out prematurely.
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I agree
I agree that in order to have the extensions applied to my lashes I will need to keep my eyes closed for the whole duration of the procedure. I also agree that I will need to be in a reclined position throughout it. Any medical conditions that may be aggravated by lying still for a prolonged period of time may mean I will not be able to have the procedure performed. I also understand and agree that the use of a mobile phone will be prohibited during the procedure.
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I agree
I agree to inform Lash Perfection of any changes to my medical circumstances that may affect my immune system such as pregnancy etc.
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I agree
I understand that Jayne Webb at Lash Perfection's liability is limited to the cost of the procedure performed. In the event of a dispute that can not be amicably resolved, Lash Perfection and the client agree to binding arbitration to resolve any disputes at the clients expense
I agree
I agree to the patch test to ascertain potential allergic reactions to the Henna products. Pigments used have a low probability of allergic reactions but can not absolutely rule out the possibility of an allergic reaction.
I agree
The risk of infection from the treatment is extremely minimal, the possibility of such an occurrence can not be totally precluded. Accordingly, I understand and accept this risk and release Lash Perfection from any liability related to the subject procedure, except instances of gross negligence.
I agreee
This agreement will remain in effect for the procedure and all future procedures conducted at Lash Perfection. I understand that this agreement is binding and that I fully understand all the above information. I am over the age of 18, if below 18 a parent or guardian must also sign this form.
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I agree
Permission is granted to Lash Perfection to take photos of my eyes/face which may be used for marketing, websites, social media, the salon or training purposes.
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I agree
Permission is granted for Lash Perfection to keep my details safe and secure and my mobile number used as my preferred method of contact. I understand my information will not be passed to a 3rd party.
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I agree
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Consent
Please read the following carefully and agree that you have read and understood all the information in the consultation form.
Lashes are made of synthetic material to simulate natural lashes. Application of the extensions will create shape, depth, definition ad enhancement with the result being thicker and fuller lashes. Its a relaxing treatment. Maintenance/infills will be required on a regular basis to keep the desired result at an additional charge.
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I agree
I authorize Lash Perfection to perform the application of eyelash extensions on myself as detailed within this consent form. I understand that the aftercare information I require will be given to me at the end of my first appointment and will be also available at my request anytime.
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I agree
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We hold your appointments just for you and ask that if you must cancel or reschedule any appointment please provide us with at least 24-hour notice. This way, we will be able to adjust our schedules accordingly and we may be able to accommodate other clients on our waiting list. We do, of course, understand that unavoidable issues come up and will do our best to work with you in case of an emergency. Last minute cancellations or ‘no shows’ will be charged a cancellation fee each time. Here is our general breakdown of cancellation fees: • Less than 24-hour notice will result in a charge equal to 50% of reserved appointment(s) • NO SHOWS’ will be charged 100% of service amount Please understand that it is your responsibility to remember your appointment dates and times in order to avoid missed appointments and cancellation fees. You are always welcome to call and double check any appointments if you’re unsure.
I agree to the above statment
Signature
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Full name of parent/guardian signing for under 18 years
First Name
Last Name
Today's date
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