New Client Eyelash Extension Consent Form

New Client Eyelash Extension Consent Form

All information is confidential.
Name

First NameLast Name
Date of birth

MonthDayYear
Date
Phone number

Area CodePhone Number
Email
example@example.com
How did you hear about Pretty Tingz?*

InstagramFacebookWeb searchFriendOther
Removal
Do you currently have lash extensions on?*

YesNo
Are you receiving a lash removal?*

YesNo
If yes, to either, please list date of application:

MonthDayYear
Date
If you currently have lashes on, are you experiencing any of the following? (Please select all that apply.)*

DiscomfortItchingBurning or stingingSwellingRednessPremature lash lossPicking or pullingN/A
Please provide relevant details that will help me customize your solution.
If you are receiving a removal or foreign fill, please provide a passport style photo so I can assess your lashes.

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Cancelof
Removal of lash extensions applied at a foreign studio may expose visible breakage, gaps, thinning, and accumulation damage as a direct result of the original application technique. Pretty Tingz By Pey is not responsible for the condition of my lashes post removal.*

I understand and acknowledgeI do not consent
History
Have you ever had eyelash extensions before?*

YesNo
If yes, please provide the date of application

MonthDayYear
Date
Please provide a description of your last set. List any helpful details that will allow me to customize your experience. Ex: Preferences, expectations, etc.
If this is your first time getting lashes, would you like to have a patch test, which I highly recommend? (Note that a patch test does not guarantee that an adverse reaction will never happen.)

YesNo
Which of the following are you receiving? (Please select all that apply.)*

Classic full setHybrid full setVolume full setForeign fillLash removal
Please select any current conditions or contraindications within the last 6 months that apply:*

Eye infectionCorneal abrasionAnxiety or panic attacksCyanoacrylate allergyGlaucomaThyroid conditionCancerClaustrophobiaOCDTrichotillomaniaBack or back painAsthmaDry eyeExcessive tearingLight sensitivityLatex allergySilicone allergySkin disordersBlepharitisHypersensitiveRecent cosmetic/facial proceduresSeizuresOveractive bladderSeasonal allergiesAllergy to glycerinAllergy to surgical glue or nail glueN/A
Please list any medications you are taking (Mark N/a if you are not taking any.)*
Please disclose any allergies not listed above (Mark N/a if you don’t have any.)*
Lifestyle
Please select any that apply to your lifestyle:*

Frequent swimmingHot yogaSaunaFacials or esthetic treatmentsActive lifestyle
What side do you primarily sleep on?*

Left sideRight sideBackOn faceOther
Skincare and makeup (Select all that apply):*

MoisturizerSunscreenSkin exfoliantsCleanserSkin serumMakeup removerEye creamEyeshadowEyeliner (gel or pencil)MascaraPowder or foundationPrimer of any kindOil based products
How often do you wear strip lashes?*

NeverOccasionallyFrequently (2-3 per week)Daily
Have you used a lash growth serum in the last 6 months?*

YesNo
If yes, please list brand:
Do you have a tendency to pick or pull on your lashes?*

YesNo
If you are receiving a full set of lash extensions, please provide a passport style photo with your eyes OPEN. (This is so I can determine your lash map based on eye shape)*

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Cancelof
Consent
*

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, Peyton Merringer.I understand and agree to the after-care instructions and for 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. I further understand that in rare circumstances eye or skin irritation and discomfort may occur.I understand that because of the natural lash cycle and wear and tear, I will need to maintain my extensions with fills every 2 to 3 weeks to keep them full.I have been provided with access to the specified procedure guide and acknowledge the policies within. I have been made aware of the risks associated with my chosen treatment. By consenting, I am waiving any provider liability and to hold Peyton Merringer and Pretty Tingz By Pey harmless.I DO NOT consent to these terms, and therefore will not receive services.
Your appointment is very important to me and each appointment time is reserved just for you. I understand that schedule adjustments are sometimes necessary; therefor I respectfully request a 24 hour notice for cancellations or schedule changes. You will receive text/email confirmation the day you reserve your appointment and another one 24 hours prior to the scheduled appointment. Please understand these reminders are provided as a courtesy and you are responsible for making any changes needed to avoid late arrivals, missed appointments or a cancellation fee. I reserve the right to charge a no show fee to the credit card on file of up to 100% of the service to those who do not show up to an appointment. After 2 no shows you will not be able to book an appointment unless it is paid in full at the time of booking. Absolutely no refunds! Clients that have an unpaid cancellation fee balance will not be permitted to book any future appointments until the balance is paid.

I acknowledge and consent to the 24 hour cancellation + rescheduling policy.I do not consent- I will be unable to accept your appointment without credit card authorization.
I release the rights to any photos taken before, during or after the procedure to be used for educational or marketing purposes.*

I do not consentI consentI consent with these limitations
Example of limitation: no full face photos, no photos showing bottom half of face, or no open eye photos. Please list:
Date

MonthDayYear
Date
Client Signature
Should be Empty:

New Client Eyelash Extension Consent Form

Removal

History

Lifestyle

Consent