client consent form

1
Name
First Name
Last Name
2
Email
example@example.com
3
Phone Number
Please enter a valid phone number.
4
I understand that a full set of lash extensions can make the appearance of my own lashes about 30-50% thicker, and make my lashes appear 20-50% longer.* This field is required.
I acknowledge
I do not acknowledge
5
I understand that lash extension services have some inherent risk of irritation to the orbital eye area, including the eye itself, and could result in stinging and burning, blurry vision, and potential blindness should the adhesive enter the eye or should an allergic reaction occur.* This field is required.
I acknowledge
I do not acknowledge
6
I understand that some irritation, itching, or burning may occur on the skin if the bonding agent comes into contact with it.* This field is required.
I acknowledge
I do not acknowledge
7
I understand that if the bonding agent comes into contact with my eye, my eye will be flushed with water and I will be assisted in seeking medical attention immediately.* This field is required.
I acknowledge
I do not acknowledge
8
I understand that this is a semi-permanent procedure, as my natural lashes will continue to grow and fall out normally, making touch-up or “fill” appointments necessary to maintain the original look achieved by replacing the lashes that have fallen out. Most clients require a fill appointment every 2-3 weeks.* This field is required.
I acknowledge
I do not acknowledge
9
I understand that while every attempt will be made to provide me with the length and fullness I have chosen, my final result may not be what I initially envisioned. I understand that all attempts will be made to rectify any concerns within the next 48 hours. All sales are final.* This field is required.
I acknowledge
I do not acknowledge
10
I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications.* This field is required.
I acknowledge
I do not acknowledge
Other
11
I understand that additional conditions could occur or be discovered during the procedure which could affect my ability to tolerate the procedure* This field is required.
I acknowledge
I do not acknowledge
12
I consent to “before and after” photographs for the purpose of documentation, potential advertising, and promotional purposes.* This field is required.
I acknowledge
I do not acknowledge
13
I understand and agree to all service policies.
I understand and agree
I do not understand and agree
14
I understand that if I have any concerns, I will address these with my lash extension specialist. I give permission to my lash extension specialist to perform the lash extension procedure we have discussed and will hold her harmless and nameless from any liability that may result from this service. I have accurately answered the questions above, including all known allergies, prescription drugs, or products I am currently ingesting and using topically. I understand my lash extension specialist will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consent the lash extension specialist immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures.Please initial.
Clear
15
I understand the procedure and accept the risks. I do not hold the lash extension specialist, whose signature appears below, 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 performed today. I certify that I have read, and fully and understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered.Please sign.
Clear
16
Date
Date
Month
Day
Year
Should be Empty: