New Client Consent Form

New Client Consent Form

Thank you for choosing Eleven XI Beautè. We look forward to servicing you!
Name*

First NameLast Name
Phone Number*
Format: (000) 000-0000.
Email*
example@example.com
Birthdate*
Instagram Username
we like to follow all of our clients :-)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
GoogleInstagramYelpCurrent Client Referral - Include name belowOther
Client Name
YesNo
YesNo
YesNo
If yes, where?...please feel free to share any additional useful detail about your experience
YesNo
YesNo
YesNo
Used Benzyol Peroxide in the past 24 hoursUsed Accutane in the past 48 hoursHad a Chemical Peel in the past 48 hoursSensitive SkinNone of the above
YesNo
YesNo
Allergies to adhesive tape, fumes or eye makeup removerDry Eye SyndromeSjorgen's SyndromeChemotherapy in the last 120 daysNone
I understand the risk associated with a lash lift.I understand and agree that if I experience any major issues with my lashes I will contact my technician and consult a physician at my own expense.To follow after-care instructions and to not get my lashes wet with water or oil for the following 24 hours.I understand and agree to the after-care instructions provided by my technician. Failure to follow the aftercare instructions may cause damage and/or loss of the natural lash. Any unexpected circumstance that have happened due to not following these instructions are at my own risk.I understand that in rare occasions there are risks associated with having a lash lift. I further understand that in rare circumstances, eye or skin irritation and discomfort may occur.I understand that in order to have the lash lift service, I will need to keep my eyes closed for duration of the procedure. Any sudden opening of my eyes or movement of my eyes during the procedure can cause my eyes to open and is a fault of my own. 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 that I will not be able to have the procedure performed.
YesNo
YesNo
LeftRight
YesNo
If yes, please list any eye drops or eye medications you are using
Allergy to adhesives, band aids or medical tapeAllergy to surgical glue or nail glueSeasonal allergiesAllergy to glycerinEye illness or injuryBlepharitis (inflamed eyelids)Permanent eye-makeupEye liftDrugs that can cause temporary hair lossMajor surgery within last 120 daysNoneOther
I hereby agree to have eyelash extensions applied to my natural lashes and consent to the placement and/or removal of the eyelash extensions by the certified professional.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 and agree that if I experience any major issues with my lashes I will contact my technician and have the eyelash extensions removed immediately and consult a physician at my own expense.I agree to use only recommended products on my Eyelash Extensions.I understand and agree to the after-care instructions provided by my technician. Failure to follow the aftercare instructions may cause the eyelash extensions to prematurely fall out. Any unexpected circumstance that have happened due to not following these instructions are at my own risk.I understand that in rare occasions there are risks associated with having artificial eyelashes applied. I further understand that in rare circumstances, eye or skin irritation and discomfort may occur.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 the procedure. Any sudden opening of my eyes or movement of my eyes during the procedure can cause my eyes to open and is a fault of my own. 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 that I will not be able to have the procedure performed.I understand that because of the natural lash cycle and wear and tear, I will need to maintain my extensions with touch up appointments. It is recommended to return about every 2 to 3 weeks to maintain fullness.I understand that less than 30% of lashes per eye or, after 30 days since the last service performed at Eleven 11 Beautè, will require a new full set.I agree to use only recommended products on my Eyelash Extensions.I acknowledge that I should not pull on my lashes after they have been applied
I understand that arriving late to my scheduled appointment time will reduce the time of my service. If I am more than 15 minutes late, I understand that my appointment may need to be rescheduled and may be subject to a rescheduling fee.I understand that I am required to reschedule or cancel my appointment at least 48 hours before the beginning of my service time. Any cancellations after that period will be subject a cancellation fee of 50% of the service price. No show appointments will be charged 100% of the service price. NO EXCEPTIONS!I understand that there is a potential possibility of allergic reaction– as with all cosmetic products.I understand this service is non-refundable. If I have any issues with my services I am to reach out to Eleven 11 Beautè within 48 hours of my service.This agreement will remain in effect for this procedure and all future procedures conducted by Eleven 11 Beautè. I understand that this agreement is binding and that I have read and fully understand allinformation above. I represent that I am over the age of 18 years. If below 18 years of age a parent or guardian must also sign this form.
If you are a New Client who'll be receiving a fill on a set not initially applied by Eleven 11 Beautè, please take a photo of your current Extensions
By signing below, I verify that I have read and understand the statements outlined and agree to them.
Date*

MonthDayYear
Date
Client Signature*

Clear
Parent or Guardian Signature (Clients under the age of 18)

Clear
I agree to have eyelash extensions applied to and/or removed from my natural eyelashes. Before my qualified professional can perform the procedure, I understand I must complete this agreement and provide my informed consent by signing and dating where indicated.

Waiver of Liability - I understand that there are risks associated with having artificial eyelashes applied to and/or removed from my existing eyelashes, and that notwithstanding 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 when improperly handled. As part of this procedure, I understand that a certain amount of eyelash adhesive material will be used to attach the artificial lases to my existing eyelashes. Even though the professional may apply or remove my lashes properly, 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 agree that I will not attribute any liability to Eleven 11 Beautè LLC and it's represntatives as a result of this procedure or the use and care of these lashes. I also agree to defend, indemnify and hold harmless Eleven 11 Beautè. LLC and it's represntatives from any and all claims, actions, expenses, damages and liabilities, including reasonable attorney’s fees which might be asserted against them as a result of my having this procedure performed. I understand that there are no refunds.

Care & Maintenance - I agree to the follow the care and maintenance instructions provided by Eleven 11 Beautè LLC and it's represntatives. The instructions provided for use, care of my eyelash extensions and any follow up care is required. If there is any mishap 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 extensions or may cause my lashes to fall off prematurely. Knowing this I agree to follow these tips for best results. I will avoid using waterproof mascara on my eyelashes. I will not use an eyelash curler, perm or tint my extensions. I have been advised that using mascara on a regular basis will shorten the length of time my extensions will remain in place. If I experience any itching or irritation, I agree to contact my Eleven 11 Beautè LLC immediately to have the lash extensions removed. I agree to not pick, pull or rub my 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 lash extensions be professionally removed.

No Known Medical Conditions/ Informed Consent - I have read and completed the consent form in its entirety and in truth. I acknowledge that I have been advised of the potential harmful or negative side effects for example, premature shedding of my natural eyelash or extension. I acknowledge that the lash extension procedure or removal may cause side effects 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. 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 Professional’s instructions or these warnings.
If any action is brought to enforce the terms of this Agreement, the prevailing party shall be entitled to its costs and reasonable attorney’s fees. This agreement will remain in effect for this procedure, and all future procedures conducted by Professional from Eleven 11 Beaute' LLC.

I agree that this Agreement is binding upon me, and my heirs, legal representatives and assigns. I represent that I am over 18 years of age and that I have the right to enter this agreement, or if I am under 18 years of age, I have had my parent or legal guardian consent to this agreement
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