Eyelash Extensions Consent Form The Lash Goddess AZ

Eyelash Extensions

Consultation & Consent Form
Name*

First NameLast Name
Phone Number

Area CodePhone Number
Birth Date: blanks*
Referred by: blanks
Client Health History
Please list any allergies you have (including cosmetics/ ingredients): blanks
YesNoDon’t Know
YesNo
YesNo
Please list all current medications you are taking (including over-the-counter herbs, vitamins and supplements): blanks
Any other health conditions not listed: blanks
Yes, but I'm able to lay still for up to 2 hoursNo
Yes, but I’m okay removing them prior to serviceNo
YesNo
YesNo
YesNo
YesNo
YesNo
RightLeftStomachBack
FastSlowNormal Rate
Is there anything else we should know? blanks
Post Treatment and Homecare
Your lash extensions are attached to your own individual eyelashes, and will shed as your natural lashes shed. Maintaining your lash extensions will require regular visits to attach new extensions (refills) to your own eyelashes as your eyelash growth cycle regenerated new lashes. With a few simple care instructions you will be on your way to enjoying your luscious long lashes. To increase the longevity of your lashes, it is advised to avoid moisture and touching as much as possible. Before your appointment: If you use waterproof mascara, avoid using it 2-3 days before your first appointment. The film it leaves on your lashes may prevent the extensions from adhering correctly. Arrive to every appointment with dry, clean lashes and makeup-free eyes. Remove contact lenses before your appointment.

During the initial 24-48 hours after your appointment: Do not get your lashes wet for 48 hours after the lash extensions are applied. It will affect the efficacy of the glue. Avoid crying, steam from showers, facials, saunas and swimming pools. Avoid getting moisture around the eye area when washing face, showering, etc.

General guidelines to extend the life of your lashes Avoid using oil-based skincare and makeup products around the eye, including mascara and makeup remover. ZERO mascara on extensions. Avoid running water over your face unless your washing them (lashes should be washed daily). Avoid rubbing your eyes or lashes, especially when washing your face. It is recommended to clean around the eye area with a lash cleanser and eyeshadow brush. Avoid applying makeup directly on extensions and come to appointment with zero makeup to avoid being charged for a lash bath. If yo would like more curl, please speak to your technician. If you can, sleep on your back to avoid the risk of lashes rubbing against your pillow. Gently brush your lashes with a lash wand to groom them. The best time to do this is after showering, as they will be softer and less likely to damage. Avoid pulling your lashes, and do not attempt to remove them yourself. If you have any problems at all with your extensions notify artist less than 3 days after appointment. If you would like them removed, please contact your technician/book for removal online. If you experience and pain, redness or irritation; contact your technican immediately. PLEASE FOLLOW ALL AFTERCARE ACCORDINGLY
Informed Consent

Although every precaution will be taken to ensure your safety and well-being before, during and after your lash extension application, please be aware of the following information and possible risks. Please Initial:
I understand that all services final. All services and deposits are non-refundable.*
Initial
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.*
Initial
I understand that the lash extension services have some inherent risk of irritation to the orbital eye areas, 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. *
Initial
I understand that some irritation, itching or burning may occur on the skin if the bonding agent becomes into contact with it. I will not attempt to open my eyes during my service.*
Initial
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. *
Initial
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 “refill” 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.*
Initial
I understand that I will need to come to my 2 week fill with a minimum of 50% retention on both eyes and 40% retention on a 3 week fill. If I show up to an appointment with little to no retention my appointment will be charged as a full set. *
Initial
I understand that while every attempt will be make to provide me with the length and fullness I have chosen, my final result may not be what I initially envisioned.*
Initial
I understand that it is imperative that I disclose all of the information requested in the client profile/health history.*
Initial
I have cited all conditions and circumstanced regarding my health history, medications being taken, and any past reactions to products or medications.*
Initial
I understand that additional conditions could occur to be discovered during the procedure which could affect my ability to tolerate the procedure.*
Initial
I content to “before and after” photographs for the purpose of documentation, potential advertising and promotional purposes.
Initial
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 him/her and his/her staff harmless and nameless from any liability that may result from this treatment.I have accurately answered the questions above, including any known allergies, prescription drugs or products I am currently ingesting or 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 consult the lash extension specialist immediately. I agree this constitutes full disclosure, and that is supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the lash extension specialist, Jacel Saldate, 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.
Signature*

CLIENT POLICIES
I understand that a NON-REFUNDABLE deposit is required. I understand that my deposit and/service will not be refunded under any circumstances.*
Initial
I understand that I must come to my appointment on time with no extra guests.*
Initial
I understand that I must arrive 5 minutes early as a new client*
Initial
I understand that I come to my appointment with clean lashes (no mascara or lash glue). I understand that if I come to my appointment with dirty lashes I will have to pay for a lash bath done during my appointment time*
Initial
I understand that if I am 4-7 minutes late there will be a $15 fee*
Initial
I understand that if I am 7-10 minutes late my appointment will be considered a no show.*
Initial
I understand that if necessary I can reschedule online with a 48 hour window and all rescheduling must be done online. I understand I cannot reschedule with the same deposit more than once. After rescheduling more than once my deposit will be forfeited.*
Initial
I understand that the no show/ last minute cancellation fee will be charged 100% of the service. I will not book an appointment unless I am 100% sure i can make it and if something comes up I will communicate. *
Initial
I understand that if necessary I must cancel/ reschedule online after the 48 hour notice a fee no show fee will be charged. If I am not able to accommodate within that window I will inform my service provider for the chance that there is another solution and to avoid being blocked from booking services in the future.*
Initial
I understand that a cancellation within a 2 hour notice is considered a no call no show. No exceptions.*
Initial

VIP APPOINTMENTS
I understand that if I don't get the chance to pre-book an appointment VIP appointments are available to my connivance at an extra fee. *
Initial
I understand that appointments starting after 6:30PM, out of business hours, and days off are considered VIP appointments *
Initial
I understand that same day appointments are considered VIP appointments *
Initial
I understand that VIP appointments are an additional 35 on top of the regular price. *
Initial
Should be Empty:

Eyelash Extensions

Client Health History

Post Treatment and Homecare

Informed Consent

CLIENT POLICIES

VIP APPOINTMENTS