Client Information
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Last Name
Address
Street Address
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State / Province
Postal / Zip Code
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Email
example@example.com
Occasionally I may send out
emails or newsletters about
upcoming discounts, promotions,
contests, company information etc.
If you would like to be added to
the subscriber list please check
“Yes” below. If you would like to
opt out please check “No”.
YES! Sign me up!
No, Thank you
Have you had eyelash extensions applied before ? If yes, why did you remove them?
Do you wear glasses?
Yes
No
Do you have frequent eye irritation, itching, or watery eyes?
Yes
No
Have you had eye surgery in the last six months?
Yes
No
Eyelash extensions require medical tape and adhesives that may contain acrylic or latex.
Are you allergic to latex?
Yes
No
Are you allergic to acrylic?
Yes
No
PLEASE CHECK ANY OF THE FOLLOWING THAT MAY APPLY TO YOU:
RELATING TO THE EYE
Eye surgery
Eye illness or injury
Dry eyes
Seasonal allergies
Eye Infection
Permanent eye make-up
Blepharoplasty
Blepharitis (inflammation of eyelids)
Allergies to cyanoacrylate adhesives (i.e. surgical glue, nail glue, crazy glue)
Hypersensitivity to formaldehyde ( aby-product released in cyanoacrylateadhesives)
Retinoids used to treat acne and skin problems (such as accutane or retin a)
GENERALLY RELATING TO EYELASHES
Hormone imbalance
Recent severe illness or injury
Pregnancy or recent childbirth
New prescriptions or recently prescribed oral contraceptives
Types of medical conditions that may contribute to hair and eyelashloss: hyperthyroidism or hypothyroidism, alopecia areata, lupus, diabetes
Vitamin and mineral deficiencies that may contribute to hair and eyelash loss:A, F, B, Selenium, Zinc, Iron
Trichotillomania (hair pulling disorder)
Medications that may contribute to hair or eyelash loss: chemotherapeutic agentsused in cancer treatment, Anticoagulants(blood thinners), beta blockers (used tocontrol blood pressure)
Other Medical Information
Client Name
First Name
Last Name
Client Signature
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Cancellation Policy
Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in my day that could have been filled by another client. As such, I require 24 hours notice for any cancellations or changes to your appointment. Clients that provide less than 24 hours notice or miss their appointment will be charged a cancellation fee. * Appointments canceled less than 24 hours before the appointment time will incur a 50% cancellation fee. * No call no shows incur a 100% cancellation fee charged.
I Agree to the Cancellation Policy
*
Initial
Late Policy
* Please let me know in advance if you are running late. If you are going to be less than 15 mins late I will still be able to accommodate you, it will just result in less time in the appointment. (example: Less time spent on lash extensions = not so full lashes). * More than 15mins late requires you to rebook and will result in you being charged the 50% late cancellation fee (This late fee does not go to future appointments).
I Agree to the Late Policy
*
Initial
Waiver of Liability
I understand there are risks associated with having artificial eyelashes applied to and/or removed from my existing eyelashes, and that not withstanding the utmost of care in the application or removal of these products, there still exist risks associated with the procedure and product itself, which include, without limitation, eye irritation, eye pain, discomfort, and, in rare cases, blindness even when applied in the usual manner. If I experience any irritation, redness, puffiness, itchiness, an allergic reaction or any other side effect of this procedure, I will contact a medical doctor immediately. As part of this procedure, I understand that a certain amount of eyelash adhesive material will be used to attach the artificial eyelashes to my existing eyelashes. Even though the eyelash extension artist may apply or remove my eyelash extensions in the usual manner, I understand adhesive material may become dislodged during or after the procedure, which may irritate my eyes or require further follow-up care, at my own expense to prevent damage to my eyes. I also understand there is more than one technique for applying eyelash extensions to my eyelashes, and I will not attribute any liability to the eyelash extension artist as a result of this procedure or the use and care of these lashes. As part of the removal procedure, I understand that a certain amount of chemical adhesive remover is applied to existing adhesives and a reaction occurs to dissolve the adhesive that results in the thinning of the remover. Even though the eyelash extension artist may apply or remove my eyelash extensions in the usual manner, I understand the liquid remover may seep into my eyes, which may irritate my eyes or require further follow-up care, at my own expense to preventdamage to my eyes. I also agree to defend, indemnify and hold harmless the eyelash extension artist from any and all claims, actions, expenses, damages and liabilities, including reasonable attorneys’ fees which might be asserted against her as a result of my having this procedure performed, or my purchase of these eyelash extensionproducts from her.
I Agree to the Cancellation Policy
*
Initial
Permission to Use Photos
I hereby grant the eyelash extension artist the full right to take, publish pictures of me, my face, my eyes and/or eyelashes, both before and after this procedure, for any advertising, education, including the right to retouch these pictures as deemed necessary by the eyelash extension artist. I further expressly assign any copyright in these pictures to the eyelash extension artist. I also grant my consent for the eyelash extension artist to use my image and likeness as contained in these pictures for any advertising or other purposes.
I Agree
*
Initial
Care and Maintenance
I agree to follow the care and maintenance instructions provided by the eyelash extension artist for the use and care of my eyelash extensions, and that if any follow up care is required due to my own mistake or negligence, or failure to follow these instructions, this will be at my own expense and risk. I understand that if I do any of the following, it may result in damage to my eyelash extensions or may cause my lashes to fall off prematurely. Knowing this I agree to follow these tips for best results:
I will avoid oil based eye products, as these will loosen the bond of my eyelash extensions.
If I experience any itching or irritation, I agree to contact a medical doctor immediately and the eyelash extension artist to have the eyelash extensions removed.
I agree to avoid using waterproof mascara and to not use an eyelash curler, perm, or tint my eyelash extensions.
I agree to not pick, pull or rub my eyelash extensions.
I understand that I should not attempt to remove my lash extensions on my own or with any product, but that the procedure requires that my eyelash extensions be professionally removed.
I understand that if I pick, pull on, or rub my eyelash extensions it may result in the premature temporary and permanent loss of my artificial and natural eyelashes.
I Agree to the Care and Maintenance Terms
*
Initial
No Known Medical Conditions / Informed Consent
I have read and completed the Eyelash Extension Intake Form in its entirety and in truth. I acknowledge that I have been advised of the potential harmful or negative side effects (such as the premature shedding of my eyelash) that the lash extension procedure or removal may cause to those who have specific medical or skin conditions. I understand that the adhesives and adhesive remover are a skin, eye and mucus membrane irritant and that in rare cases persons may be allergic or have hypersensitivity to synthetics, cyanoacrylate or formaldehyde, which in small amount may be present in the adhesive. I understand that the procedure requires that I lay still for up to 2 hours or longer with my eyes shut, and that if I wear contacts, I must remove my contact lenses for the duration of the lash extension application or removal. I further state that I have no known medical condition that might be aggravated by the procedure or any medical condition that would prevent me from complying with or heeding to the eyelash extension artist's instructions or these warnings.
I Agree
*
Initial
Patch Test
I understand, that should I have any concerns about any possible reaction to chemicals and products used, I may arrange at my own discretion to book an advance spot test where 2 to 3 individual lashes will be applied 24-48 hours prior to the time in which I’m scheduled for my initial full set. I further agree, that this shall be my own responsibility and at my sole discretion, and have absolutely no bearing on the contents or signing of this agreement or any clauses contained therein.
I Agree
*
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