Bat Dat Lash by Rosie

Bat Dat Lash by Rosie

EYELASH EXTENSION CONSENT FORM
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
YesNo
YesNo
YesNo
Current use of contact lenses which I agree to remove during eyelash extension applicationCurrent use of eyedrops of any kind, prescription or over-the-counterCurrent use of anything such as oil-containing sunscreen or moisturizers around the eyesCurrent allergies or sensitivities to instruments, fumes, tapes, cleaners, eye gel pads, adhesives, and removers that could cause my eyes to water and blinkHistory of claustrophobiaHistory of recurrent eye or tear duct infectionsHistory of dry eyes or Sjorgen's SyndromeRecent history of ChemotherapyOther medical conditions which would prohibit or compromise placemet and retention of eyelash extensions.None of the Above
No waterproof mascaraNo prescription or over-the-counter eye dropsNo oil based products around the eye areaNo water can come in contact with the eye area for 24 hours of the applicationNo tinting or perming of eyelash extensionsNo continuous pulling or rubbing of the synthetic lashes
YesNo
I understand there are risks associated with having artificial eyelashes and eyelash extensions applied to, or removed from my natural eyelashes. I further understand that as part of the procedure, eye irritation, eye pain, eye itching, discomfort, and in rare cases, eye infection or blindness can occur. I agree that if I experience any of these medical conditions with my lashes I will contact the certified eyelash extension professional and have the eyelashes removed immediately and consult a physician at my own expense. I understand that even though the certified eyelash extension professional applies or removes the eyelash extensions using the proper technique, the instruments, tapes, cleaners, eye gel pads, adhesives, and removers used may irritate my eyes or require a physician's follow-up care and subsequent removal of the eyelash extensions.

I understand and agree to the care instructions provided by the certified eyelash extension professional for the use and care of my eyelash extensions. I realize and accept the consequences of failure to adhere to these instructions may cause the eyelash extensions to fall out, damage the extensions and/or decrease the time the lashes will last.

I agree to my eyelash extension professional using my photo and/or video in any online communities or forums (including but not limited to Facebook, instagram and other online media sources My eyelash extension professional's right of use shall include the right to publish, adapt, exhibit, reproduce, edit, distribute and display my image or likeness in connection with any product or service for any purpose (including, promotion advertising and trade) in all markets, media or technology now known or hereafter developed. I shall not have any entitlement to compensation for any content used.

By signing below, I verify that I have read and understand the above statements and agree to them. (An insurance release form may also need to be signed that provides coverage for this procedure)
Signature
I release my technician from all liability associated with this procedure, which is performed with the utmost attention to safety and proper application using tools and products that the technician has been professionally trained to use. There is no guarantee for the bonding time of the eyelash extensions. I understand the after care instructions and will do my part to maintain my eyelash extensions. I understand that there are many factors that may affect the life of the eyelash extensions such as water and moisture contact, weather conditions, and activities involving exposure to high temperatures.

YesNo
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Technician Signature
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Bat Dat Lash by Rosie

Policies & Preperation