Eyelash Extension

Name*

First NameLast Name

Phone Number*

Format: (000) 000-0000.

YesNo

The following conditions may NOT be suitable for eyelash extensions. Please contact your lash artist to discuss any concerns before your appointment. PLEASE CHECK ANY OF THE FOLLOWING THAT MAY APPLY TO YOU:

Eye surgery in the last six monthsEye illness or injuryChronic dry eyesFrequent eye irritation, itching or watery eyesRecent or current eye infectionBlepharoplasty in the last 6 monthsBlepharitis (inflammation of eyelids)Allergies to cyanoacrylate adhesives (i.e. surgical glue, nail glue, crazy glue)Hypersensitivity to formaldehyde (a by-product released in cyanoacrylate adhesives)

Types of medical conditions that may contribute to hair and eyelashloss: hyperthyroidism or hypothyroidism, alopecia areata, lupus, diabetesMedications that may contribute to hair or eyelash loss: chemotherapeutic agents used in cancer treatment, Anticoagulants (blood thinners), beta blockers (used to control blood pressure)

Other medical information not listed pertaining to the eyes?

YesNo

Please initial below: First Class Novas has certain policies in place to protect time that is set aside especially for you and make sure you are getting our full undivided attention, and of course the best lash work! Initialing below confirms that you have read the policies on my Instagram highlight "Policy" and/or on my website prior to booking.

I agree to the above statements*

Initial

I understand there are risks associated with having artificial eyelashes applied to and/or removed from my natural eyelashes. I understand that the eyelash extensions will be applied to the natural lash as determined by the technician so as not to create excessive weight on the natural eyelash thereby preserving the health, growth and natural look of the client’s natural eyelashes. I understand as part of the procedure eye irritation, eye pain, eye itching, discomfort and in rare cases eye infection may occur. I understand and agree that if I experience any of these issues with my lashes that I will contact my technician and consult a physician at my own expense. I understand that even though the technician may apply and remove the eyelashes properly, that adhesive materials 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 after care instructions provided by my technician. Failure to follow the after care instructions can cause the eyelash extensions to fall out. I understand that in order to have the eyelash extensions applied to my eyelashes I will need to keep my eyes closed for duration of 2 hours or longer during the procedure. If I wear contacts, I may be asked to remove my contact lenses for the duration of the lash extension application or removal. I also understand that I will need to be lying in a reclined position. Any medical conditions that might be aggravated by lying still for a prolonged period of time may mean I will not be able to have the procedure performed on my eyes.

This agreement will remain in effect for this procedure and all future procedures conducted by my lash artist. I understand that this agreement is binding and I have read and fully understand the information listed above. I also agree to defend, indemnify and hold harmless the eyelash extension artist from any and all claims, actions, expenses, damages and liabilities as a result of having this procedure performed.

I agree to the above statements*

Initial

Full Name*

First NameLast Name

Client Signature*

Date*

Date

Lash Extension Form + Policies

Policies

Waiver of Liability