Anna Aesthetics Eyelash Extension Consent Form

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Have you received eyelash extensions before?

Have you had permanent cosmetics applied to your eye area?

Do you wear contacts?

Do you have or are you being treated for any eye illness or injury?

Are you able to lay on your back for 2+ hours to have your lashes applied?

Have you ever had eyelash extensions removed?

Are you allergic to adhesives (cyanoacrylate, latex, gel pads etc.)?

Have you had eye Surgery in the past 4 months?

Disclaimer I understand that this procedure requires single synthetic eyelashes to be glued to my own natural eyelashes. 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 agree to disclose any allergies that I may have to latex, surgical tapes, cyanoacrylate, Vaseline, etc. I have also had the opportunity to decline a patch test and say I do not wish to have the patch test before the treatment is carried out. I authorize the taking of photographs and videos. I understand that photographs and video may be taken of me for educational and marketing purposes. I hold the practitioner harmless for any liability resulting from this production. I understand that if irritation were to occur, I have 3 days from my service to contact my artist for a complimentary removal. No refunds will be given. I also understand that I have a 5 minute grace policy for being late to my appointment, and after the 5 minute mark I will be charged a $25 late fee. Any no call no show appointments will be charged the full service amount, and cannot book again. Last minute reschedules and cancellations will be charged 50% of the service amount. I waive my rights to any royalties, fees and to inspect the finished production as well as advertising materials in conjunction with these photographs. I certify that I have read the above consent and I fully understand it. I have been given ample opportunity for discussion and all my questions have been answered to my satisfaction. I hereby consent to this procedure. This constitutes the full disclosure and any previous verbal or written disclosures.

Initial

The World Health Organization has declared the novel Coronavirus (COVID-19) a worldwide pandemic. Due to its capacity to transmit from person-to-person through respiratory droplets, the government has set recommendations, guidelines, and some prohibitions which XYZ Company, LLC. (the "Organization") adheres to comply.

By signing below I acknowledge that I have read the foregoing Liability Release Waiver and understand its contents; that I am at least eighteen (18) years old and fully competent to give my consent; That I have been sufficiently informed of the risks involved and give my voluntary consent in signing it as my own free act and deed; that I give my voluntary consent in signing this Liability Release Waiver as my own free act and deed with full intention to be bound by the same, and free from any inducement or representation. This waiver will remain effective until laws and mandates relevant to COVID-19 are lifted.

FOLLOWING THE PRONOUNCEMENTS ABOVE I HEREBY DECLARE THE FOLLOWING:

With full knowledge of the risks involved, I hereby release, waive, discharge the Organization, its board, officers, independent contractors, affiliates, employees, representatives, successors, and assigns from any and all liabilities, claims, demands, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, injury, or death, that may be sustained by me related to COVID-19 while participating in any activity while in, on, or around the premises or while using the facilities that may lead to unintentional exposure or harm due to COVID-19.

Signature