πππππΌππ πππππππππ
Client Information Form
Client Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Have you had eyelash extensions applied before ? If yes, why did you remove them?
Do you wear glasses?
Yes
No
Do you have frequent eye irritation, itching, or watery eyes?
Yes
No
Have you had eye surgery in the last six months?
Yes
No
Eyelash extensions require medical tape and adhesives that may contain acrylic or latex.
Are you allergic to latex?
Yes
No
Are you allergic to acrylic?
Yes
No
PLEASE CHECK ANY OF THE FOLLOWING THAT MAY APPLY TO YOU:
I wear contact lenses
I wear glasses
I frequently have eye irritations, itching or watery eyes
I had eye surgery in the last 6 months
I've had eyelash extensions before
I've had issues with eyelash extensions in the past (if yes, please describe below)
Recently had lash lift/tint for the past 3 months
None
Any history of the following
Eye infection
Watery or Sensitive eyes
Allergies to latex
Allergies to adhesive or synthetic
Blepharitis (inflammation of the eyelid) or lash mites
None
Other Information
πππππΌππ πππππππππ - Intake & Consent Form
By: Vernaartistry
By checking the following boxes, I agree to the terms and conditions.
I understand that the eyelash extensions will be applied to the natural lash as determined by VERNA ALCANTARA so as not to create excessive weight on the natural eyelash, thereby preserving the health, growth and natural look of my natural eyelashes.
I understand that as part of the procedure,Β eye irritations,Β pain, itching, redness, discomfort and in rare cases, eye infection MAY occur.
I understand and agree that if I experience any of these issue with my lashes I will contact VERNA ALCANTARA, have the eyelash extensions removed immediately and consult a physician at my own expense.
I understand that in order to have eyelash extensions applied to my eyelash I will need to keep my eye closed for duration of 60-180 minutes during the procedure and very precise application. I also understand it is my responsibility to lay still. Any medical conditions that might be aggravated by lying still for a prolonged period of time may mean that I will not be able to have the procedure performed on my eyes.
I understand and agree to follow the aftercare instructions provided. Failure to follow the aftercare instructions may cause the eyelash extensions to fall out.
I agree to show up to my appointment without any makeup. If I show up with make up, it will need to be removed. Extension application time may be reduced due to time spent on removing make up.
If I scheduled 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 21 days since last service a custom price or full set will be charged.
I understand that a deposit ($25 of service) is required to book a service (non-refundable)
If I need to cancel any of my appointments, I will inform you ASAP. I will forfeit my deposit if I give less than 48 hours notice, and/or agree to pay a rescheduling fee ($25 of service) or if no call/no show (100% of service), - there will only be 2 strikes.
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 (100% of service).
This agreement will remail in effect for this procedure and all future procedures conducted by VERNA ALCANTARA. I understand that this agreement is binding and that I have read and fully understand all the information above. I represent that I am over the age of 18 years. If below 18 years of age a parent or guardian must also sign this form.
I release VERNA ALCANTARA from all liability associated with this procedure. There are no guarantees for bonding time length of the eyelash extensions. I understand I have been advised to follow the aftercare protocol from my technician so as to avoid any discomfort or adverse side effects after the procedure has been completed.
I hereby grant permission to VERNA ALCANTARA to use photographs and/or video of me taken during my appointment for online marketing of the business.
VERNA ALCANTARA does not refund any services rendered.
I had read, understand and AGREE to ALL VERNA ALCANTARA terms.
Full Name
First Name
Last Name
Client Signature
Date
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Month
Β -
Day
Year
Date
Submit
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