Eye Lash Extensions Intake & Consent Form
*You must be 18 years or older to complete form. Minors will need their parent/legal guardian consent.
Date of service:
*
-
Month
-
Day
Year
Date
Full Name
*
First name
Last name
Birthdate::
*
-
Month
-
Day
Year
Date
Cell Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
I grant permission to Beauty Lux by Azures to use my before and after photos for marketing or examples of my technicians work.
*
Yes
No
I release Azure-Dee Mendoza DBA Beauty Lux by Azures from any and all liability associated with this procedure. This service will be performed with the utmost attention to safety, sanitation, and proper application using tools and products that the technician has been trained and certified to use. This service has many variables due to lifestyle, moisture, weather, extreme temperatures, natural eyelash shedding and other factors. The technician (along with my consent form and consultation) will decide if I am a good candidate for this service to the best of their ability.
*
Initial
I acknowledge and understand that the studio doesn’t offer refunds. Beauty Lux by Azures will do their ultimate BEST to provide a service experience to meet your satisfaction and expectations to LOVE your lashes every appointment.
*
Initial
Late Arrival: If you arrive late we will not be able to extend your appointment time, and the result of your treatment may not be optimal. If you are 15 minutes or more late to your appointment, no services will be performed unless accommodations can be made. I understand if an accommodation is made a fee of $15 will be charged at the time of appointment. If no accommodations can be made, a fee of 50% of the booked service will be charged to the card on file. If a deposit was made, deposit will be forfeited and the remaining balance of the 50% fee will be charged. Cancellation Policy: If you are unable to make your scheduled appointment please contact us as soon as possible to reschedule. We require a 24 hour notice for cancellation or reschedules. Anything less than 24 hours will result with a fee of 50% of the service booked. *Noncompliance with these policies will result in forfeiture of booking deposit. I acknowledge and fully understand the cancellation and late policy of Beauty Lux by Azures.
*
Initial
Eyelash extensions require on-going maintenance (similar to a nail service). Refills are recommended approximately every 2 to 3 weeks, and must have 40-50% of eyelash extensions left to be considered a fill. I understand if I go beyond this recommended time it may result to an incur (higher) service cost as a full-set.
*
Initial
Is this your first time having Eye-lash Extensions?
*
Yes (I'm EXCITED!)
No (I'm a Diva, I need them 4 EVER!)
Are you having lash extensions applied for?
*
Special occasion
Daily wear
Do you wear Contacts?
*
No
Yes
Do you often rub, pull or pick your lashes for any reason?
*
Yes
No
Do you have a severe eye illness or are you being treated for an eye injury?
*
Yes
No
How do you usually sleep? Please note, you will lose more eyelash extensions on the side on which you sleep. Sleeping on your stomach will affect them the most. It is important to refrain from sleeping on your stomach for the first 2 days after your service to allow the adhesive to set properly.
*
Side
Stomach
Back
Are you able to lay on your back for 2 - 3 hours to have your lashes applied?
*
Yes
No
Are you pregnant?
*
Yes
No
It is also recommended to avoid all oil-based products around your eyes for as long as you wear your lashes. Oil based products, waterproof mascaras and liners will loosen the adhesive and your lashes will not last long. Let's talk approved products during your appointment. Please come to your appointments with no eye-makeup.
*
Please initial you read and understand the above.
Do you use lash growers such as Lattice or over the counter ones? It is best to discontinue use of these type of products 2 weeks before your service and discontinue use while you are wearing your lash extensions. Some contain oils/steroids and will shorten the duration of your extensions. There is eye-lash extensions approved products for your natural lashes that we can recommend while you have extensions.
*
Yes
No
The following conditions are not suitable for eyelash extensions. Possible adverse reactions are listed below each condition
Are you allergic to adhesives (glues, tapes, band aids, etc)? This service may use adhesives tapes, glues and gel pads that may cause an allergic reaction. We use a medical grade, formaldehyde free glue, but allergies may still occur?
*
Yes
No
Have you had Chemotherapy treatments in the last 6 months? Medication for chemotherapy may cause a reaction to the materials used in this service. Also, if lashes are just starting to grow back they may be a little weak and we recommend waiting until they are strong enough for this service.
*
Yes
No
Have you had Lasik Surgery in the past 4 months? Eyes may have sensitivity to eyelash extensions and products used for prepping the eye area. (gel pads, glues, etc.)
*
Yes
No
Are you currently taking Thyroid Medications? Thyroid medications or Thyroid conditions may not have lash extensions last long due to either of these conditions.
*
Yes
No
Blepharoplasty or other eye condition or surgery in the last 6 months? Blepharoplasty, eye surgery or conditions may have sensitivity to eye-lash extensions and products used. Consult your doctor first and ask if it's safe for you to have this service
*
Yes
No
I agree and understand that Beauty Lux by Azures & my Lash Technician have no way of knowing if the client is allergic to some of the products or materials being used in any eye-lash procedure, though we do use sensitive eye products to ensure comfort every client is different. Beauty Lux by Azures does offer patch tests to those that are not sure if they are a good candidate and will help to discuss options. I will seek medical care (at my own expense) and contact my technician immediately if any allergic or adverse reaction occurs. All of my questions were answered and I understand the procedure and risks.
*
Initial
Thank you giving us the time to get to know YOU & signing the Consent form, its much appreciated towards your lash experience!
*
By signing below, I verify that I have read and understand the above statements and agree to have answered medical questions honestly to my knowledge.
Sign date
*
-
Month
-
Day
Year
Date
Client/Parent or Guardian (if minor) signature
*
I'm Ready Girl! XOXO
Should be Empty: