30 Lashes
Client Agreement and Waiver Form
Full Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Check the conditions that apply to you or to any members of your immediate relatives:
*
Alopecia (loss of hair)
Any disease causing twitch ing, shaking or erratic movements
Bells past or any condition that makes the eyes open or close properly
Blepharitis (an ocular condition characterized by chronic inflammation of the eyelid
Chemotherapy
Claustrophobia
Contact Lenses
Cysts near the eyes or brows
Dry eye syndrome
Eye infections such as conjunctivitis or imperial
Eye infections such as Uveitis
Glaucoma
Hay fever/Rhinitis
Hordeola or styes
Hypersensitive skin/Eyes
Previous reactions to collagen
Keratitis (iinflammation of the cornea)
Post Chemotherapy
Skin disease, skin trauma, cuts, abrasions, burns, and swelling
Skin disorders in the eye or brow areas (Dermatitis, Xanthelasma, and Syringoma)
Trichotillomania (impulse control disorder and is the compulsive urge to pull out one's hair)
Weak eyelashes
Watery eyes
Negative reaction to a patch or sensitivity test (allergy. Patch test MUST be done 24-48 hrs before service).
Lash and Brow Services Liability Waiver - Please check all boxes
*
I understand there are risks associated with having beauty enhancement services. Please check all the services you will be receiving or interested in for future appointments:
Lash Lift and Tint
Lash Lift
Lash Tint
Brow Laminating and Tint
Brow Laminating
Brow Tint
Henna Brow
Lash Extenstions:
Classic; or
Hybrid
Styles:
Natural eye;
Open Eye;
Whispy;
Kitten eye; or
Reverse Kitten eye (Consultation with the tech can also determine a flattering lash map if you are undecided).
I understand the lash extensions will be applied to the natural lash as determined by the technician so as not to create excessive weight on the natural lash, thereby preserving the heath, growth, and desired look of the client's lashes.
I understand that as part of any of the above procedures, eye irritation, pain, itching, discomfort and in rare cases, eye infection may occur.
I understand and agree that if I experience any of these issues, I will contact my technician and have the extensions removed immediately and consulting a physician at my own expense.
I understand that even though the technician may apply and remove the extensions properly, the adhesive material may become dislodged during or after the procedure, which may irritate my eyes or require further follow up care.
I understand and agree to follow the aftercare instructions provided by my technician. Failure to follow the aftercare instructions may cause the lash extensions to fall out.
I understand that in order for the services to be successful, I will need to keep my eyes closed for the duration of the procedure (approximately 60-180 minutes).
I understand that if I am unable to be in a reclined position, which may aggravate any health conditions, I will not be able to have the desired service(s).
I understand this agreement will remain in effect for this procedure and all future procedures conducted by my technician or any other technician at 30 Lashes.
I understand this agreement is legally binding and that I have read and fully understood all information above.
I represent that I am 18 years old or older. If below 18 years old, a parent or legal guardian must also sign the Agreement and Waiver form.
I release my 30 Lashes technician from all liabilities associated with this (these) procedures.
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.
Do you have any known or suspected allergies or intolerances to adhesives or latex?
*
Yes
No
Not Sure
Name
*
First Name
Last Name
Signature
*
If under the age of 18, a parent or legal guardian must sign and be present at the appointment:
Parent or Legal Guardian First Name
Last Name
Signature
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