Eyelash Extension Consent & Waiver of Liability
Although every precaution will be taken to ensure your safety and wellbeing before, during and after your lash extension application, please be aware of the following information and possible risks.
Name
First Name
Last Name
Date of Birth
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Day
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Month
Year
Date
Email
example@example.com
Phone Number
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Area Code
Phone Number
Have you ever had eyelash extensions before?
Yes
No
If yes, what type and was there any discomfort during or after the procedure?
If no, we recommend a patch test. Please initial if you are opting out of the advised adhesive patch test
Please initial that you understand that a patch test does not guarantee that a adverse reaction will not happen.
Have you had any allergies or an allergic reaction?
Yes
No
If yes, please clarify...
Do you have or had any of the following ?
Allergy to Adhesives (glues, tapes, band aids, gel pads, etc.)
Lasik Surgery less than 4 months (must wait 4 weeks post-op exam for medical consent)
Contact Lenses (if yes, please remember to remove them before your appointment)
Are you able to lay on your back for 2+ hours?
Do you have any known pet allergies?
Yes
No
Unsure
Will you require any additional accommodations?
Have you traveled outside the U.S. to a country that has been affected by COVID-19 in the past 14 days?
Yes
No
Have you come in contact with someone who recently tested positive for COVID-19?
yes
no
CLIENT WAIVER & RELEASE
Please read each statement and acknowledge by checking each box by doing so you have READ, UNDERSTOOD and AGREE to the TERMS.
Please read each statement and acknowledge by checking each box:
I agree to have eyelash extensions applied to my natural eyelashes and/or removed and retouched. By signing this agreement, I consent to the placement and/or removal of the eyelash extensions b y the certified eyelash extension professional.
I understand that in rare occasions there are risks associated with having artificial eyelashes and eyelash extensions applied to or removed from my natural eyelashes. I further understand that in rare cases as part of the procedure eye irritation and discomfort could occur. I agree that if I experience any of these conditions with my lashes that I will contact the certified eyelash extension professional that performed this procedure and it may be beneficial to have the eyelashes removed.
I understand that additional conditions could occur or be discovered during the procedure which could affect my ability to tolerate the procedure.
I understand that if I have mentioned to having any previous reactions and/or complications or anything that my technician sees as being a possible risk, I may be requested to have a patch test 24hrs before the full application to ensure I will not have any further risks with this application or any further applications from my technician.
I understand and agree to the aftercare instructions provided by the certified eyelash extension professional for the use and care of my eyelash extensions. I realize and accept the consequences that failure to adhere to these instructions may cause the eyelash extensions to fall out and/or decrease the time the lashes will last.
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.
I understand that it is my responsibility to keep my eyes closed and be still during the entire procedure, until my eyelash technician addresses me to open my eyes. I understand that some risks of this procedure may be but are not limited to eye redness, swelling of eyelids and irritation. The fumes from the adhesive may cause my eyes to water if I open my eyes
I understand that this is a semi-permanent procedure, as my natural lashes will continue to grow and fall out normally, making infill appointments necessary to maintain the original look achieved by replacing the lashes that have fallen out. Most clients require an infill appointment every 2-3 weeks with having 40% of eyelash extensions still attached.
I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications.
I consent to “before and after” photographs for the purpose of documentation, potential advertising and promotional purposes. I understand that if I have any concerns, I will address these with my lash extension specialist.
I understand there are risks associated with having artifical eyelashes applied to and/or removed from my existing eyelashes, and that not withstanding the utmost of care in the application or removal of these products, there still risks associated with the procedure and product itself, which include, without limiation, eye irritation, eye pain, discomfort, and in rare cases, blindness even when applied in the usual manner.
As part of the removal procedure, I understand that a certain amount of chemical adhesive remover is applied to exsiting adhesives and a reaction occurs to dissolve the adhesive that results in thinning of the remover. Even though the eyelash extension artist may apply or remove my eyelash extensions in the usual manner, I understand the liquid remover may seep into my eyes, which may irritate my eyes or require further follow up care, at my own expense to prevent damage to my eyes.
The agreement will remain in effect for this procedure and all future follow ups conducted by the certified eyelash extension professional. I read English and understand that this consent agreement is legal and binding. I have read and fully understand all information in this agreement and hereby release any and all persons representing this salon from all claims, demands, damages, actions and cause of action arising out of ther performance of the service. I have fully disclosed all condtions regarding my health history, medications and past reactions to products, treatments and medications. I am over 18 years of age and consent to the agreement and to the eyelash extension application procedure.
Signature
Date of Signature
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Month
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Day
Year
Date
Submit
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