EtsyExtIntakeandConsent

Eyelash Extensions Intake & Consent Form

Name:

Date:

Date

Address:

Birthday:

City:

State:

ZIP:

Phone:

Email:

example@example.com

Occupation:

How did you hear about us?

WebsiteWeb searchSocial:Friend:

Is this the first time you have had lash extensions applied? ❑ Yes ❑ No

If no, where have you had them applied?

Are you having lash extensions applied for:

Special occasion

Are you having lash extensions applied for:Daily wear

Do you wear contact lenses? ❑ Yes ❑ No * If yes, removal is recommended Do you habitually rub, pull, or pick your lashes for any reason? ❑ Yes ❑ No Do you have, or are you being treated for any eye illness or injury? ❑ Yes ❑ No

Are you able to keep your eyes closed and lie still for up to 2 hours or longer?

YesNo

Please check off any of the following that might apply to you:

Lasik Eye SurgeryDry Eye

Dry Eye

Seasonal AllergiesAllergies to adhesives or synthetics

Allergies to adhesives or synthetics

Childbirth within last 120 daysAlopeciaHypersensitivity to cyanoacrylate or formaldehydeHormonal imbalance or extreme stressChemotherapeutic agents used in cancer treatmentDrugs that cause temp. hair loss:

Drugs that cause temp. hair loss:

*Note: Your privacy is important to us. We will not sell or share your personal information with third parties, unless required by law.

Eyelash Extensions Intake & Consent Form

I understand that this procedure requires:

(classic individual or volume fan) on a single natural eyelash

synthetic eyelashes to be glued on to my own natural eyelashes using the very precise application of placing an extensionlifting solution and/or tint applied to my own natural eyelashes,

and it’s my responsibility to keep my eyes closed and be still during the entire procedure. Please no company during appt. I am informed of potentially harmful or negative side effects that may be caused by the application or removal and release the Lash Technician from all liability associated with this procedure.

I understand that some risks of this procedure may result in, but not limited to, eye redness and irritation. The products

used may release fumes and can cause my eyes to water. If any unusual symptoms, injury or allergy is suspected, all future appointments will cease until cleared by your physician.

I agree to disclose medical conditions including skin conditions and/or any allergies that I may have to latex, surgica

I agree to disclose medical conditions including skin conditions and/or any allergies that I may have to latex, surgical

tapes, cyanoacrylate, etc. If yes, list:

During the first 24 hours following every lash procedure/application, I agree to avoid: wetting the lashes, swimming

pools, steam from showers, saunas and tanning beds. While wearing extensions, I will follow the aftercare instructions given to me, especially, daily cleansing.

I understand that a deposit (30% of service) may be required for booking (non refundable) and is subject to change

at any time. No refunds will be issued on services, exchanges are made on defective items only.

If I need to cancel any of my appointments, I will inform you ASAP. I will forfeit my deposit if I give less than a 24 hr.

notice, and/or agree to pay a rescheduling fee (50% of service) or if no call/no-show (100% of service) if spot can’t be filled.

Arriving late will reduce the time of service. If I am more than 15 minutes late, I understand my appointment may

need to be rescheduled and will be subject to the no-show fee above.

If I schedule for a fill, at least 50% of extensions per eye should be in place at the time of my appointment. If there are after full will

If I schedule for a fill, at least 50% of extensions per eye should be in place at the time of my appointment. If there are

less than 50% or after 30 days since last service, a custom price or full set will be required.

I agree to show up to my appointment without any eye makeup. If I show up with makeup, it will need to be removed

(cleansing fee $10). Extension application time may be reduced due to time spent on removing makeup.

Facebook, Instagram, website, etc. Please mark:

I give permission to “Lash Business” to show my before and after photos and/or videos to other potential clients e.g.YesNo

Facebook, Instagram, website, etc. Please mark:

cell phone number is provided Preferred correspondence: ❑Phone/Text ❑EmailI consent to having a text message and/or email reminder 24-48 hours before appointment if so, please make sure

I consent to having a text message and/or email reminder 24 48 hours before appointment (if so, please make sure

example@example.com

I understand "Lash Business" reserves the right to refuse service to anyone at any time for any reason.

have been offered a patch test and

I have been offered a patch test and

patch test was performed ❑ I decline a patch test.I confirm and agree that I wish to engage the services of the Lash Technician.

Client Signature:

Client Name (Print):

Parent / Guardian (if under 18 years):

Date:

Date

*Note: Your privacy is important to us. We will not sell or share your personal information with third parties, unless required by law.