Appointment Date
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Month
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Day
Year
Date
Name
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First Name
Last Name
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
How did you hear about us? (name referral can be mentioned in other)
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Google
Instagram
Facebook
Family/Friends
Other
Is this the first time you have had eyelash extensions applied?
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Yes
No
What side do you predominately sleep on?
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Left
Right
Back/Front
Do you currently use anything for your eyes? (eyedrops, contact solutions, etc.)
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Yes
No
Please check off any of the following that might apply to you:
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Lasik Eye Surgery
Permanent eye make-up
Blephroplasty (eye lift)
Microdermabrasion
Allergies to adhesives or synthetics (cyanoacrylate or latex)
Child birth within last 120 days
Alopecia
Thyroid diseases
Hypersensitivity to cyanoacrylate or formaldehyde or certain adhesives/glues
Hormonal imbalance or extreme stress
Drugs that can cause temporary hair loss:
Chemotherapeutic agents used in cancer treatment
Retinoids used to treat acne and skin problems (such as Accutane or Retin A)
Oral contraceptives (birth control pills)
History of recurrent eye or tear duct infections
History of dry eyes or Sjorgen’s Syndrome
None
Other
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 by the certified eyelash extension professional.
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I agree
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.
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I agree
I understand and agree to the after-care instructions provided by the certified eyelash extension professional for the use and care of my eyelash extensions. I realize and accept the consequences of failure to adhere to these instructions may cause the eyelash extensions to fall out and/or decrease the time the lashes will last.
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I agree
I understand and consent to having my eyes closed and covered for the duration of approximately 60-120 minute procedure. Times may vary depending on the type of service.
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I agree
I understand that there will be a no refund policy as material cost and time cannot be reimbursed. I understand that there is a 48 hr grace period and will reach out to the lash artist to resolve any issue with my lashes. After that period, it is my responsibility to take care of my lashes to the best of my ability.
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I agree
This 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. I am over 18 years of age and consent to the agreement and to the eyelash extension application procedure. I understand that there will be a no refund policy as material cost and time cannot be reimbursed. I understand that there is a 48 hr grace period and will reach out to the lash artist to resolve any issue with my lashes. After that period, it is my responsibility to take care of my lashes to the best of my ability.
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I understand and agree
Optional Photography Release Consent
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I hereby grant Transform Beaute LLC the full right to take, publish and reproduce photographs of me, my face, my eyes and/or eyelashes, both before and after this procedure, for any advertising, education, or other purposes whatsoever, including the right to retouch these photographs as deemed necessary. I further expressly assign any copyright in these photographs for any advertising or other purposes, along with any comments I may provide.
No, please do not use my pictures
Signature
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Submit
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