Lash Procedure Consent & Intake

Date

Name

First Name Last Name

Phone Number

Area Code Phone Number

Email

example@example.com

I authorize Niš Beauty to provide and apply the following services and or services: semi-permanent eyelash extensions/ brow henna/ lash & brow lift & tint/lash extension removal. In order to minimize risk of injury, I understand that it is my responsibility to lie or sit completely still for the entire procedure or until otherwise directed by the technician. I have been fully informed regarding the methods and procedures used in the application and aftercare recommendations. All risks and potential complications, including but not limited to, redness, irritation, and allergic reactions to either the adhesive, eye pads, or any other products used have been fully disclosed to me. I certify that I understand these risks and potential complications, and that I knowingly and voluntarily consent to the application or removal for any of the services listed above. If at any time I feel uncomfortable during the procedure, I agree to immediately notify the the technician. The technician will see to remedy the problem, including ending the session if it is deemed prudent by the technician. I acknowledge that no guarantees or promises regarding the appearance or longevity of the eyelash extensions, henna brows, or lash tinting. I herby certify that I have disclosed all conditions regarding my health history, and past reactions to products, treatments and medication I am currently or recently using.

I understand and consent to having my eyes closed and covered for the duration of up to 3 hour procedure. Times may vary depending on the type and number of eyelashes applied.

Yes No

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

Yes No

I acknowledge that the natural lash cycle is sixty to ninety days. When one lash falls out, there is another lash growing in. I, therefore, understand that I will need regular fills, every one to three weeks, to keep my lashes looking beautiful and full. I understand that variables, including the natural lash cycle and home care, will influence the longevity of eyelash extensions.

Yes No

Do you experience allergies?

Yes No

If yes, please explain:

I agree to avoid steam from showers, saunas, and swimming pools and avoid tanning beds for the first 48 hours following the lash application

Yes No

I agree to avoid getting lashes wet for the first 24-48 hours following my lash extension application

Yes No

I agree to avoid oil-based skincare, mascara and cleansing products. I understand that water-based oil-free products are approved. I understand that oil-based products, including oil-based eyeliner, will affect the adhesion and cause lashes to fall off prematurely.

Yes No

I understand that avoiding all mascara, including "Extension Safe Mascara" is recommended by Niš Beauty. I understand mascara will interfere wit the adhesive bond with disastrous results.

Yes No

I agree to inform all service providers regarding my semi-permanent eyelash extensions when going for facial work. I understand that caution is recommended when having services such as lasers, chemical peels, hydroxyl treatments, or any other acidic substances applied.

Yes No

I agree to keep my lashes brushed with a lash wand and clean. I understand that touching my lashes with my fingers has the potential to introduce germs, oil, and bacteria to the eye area and can result in poor retention, breakage of lashes, and infection.

Yes No

I agree to avoid the use of eyelash curlers (heated and non heated) and chemicals such as lash perms while I have lash extensions applied.

Yes No

I agree to use only recommended products on my eyelash extensions and fully understand that careful maintenance is also required.

Yes No

Please check all that apply and are relevant. I am informing my technician of the following:

Current use of contact lenses Current use of eye drops of any kind, prescription or over-the-counter Current use of oil based products such as sunscreen, moisturizer, face wash and make-up History of recurrent eye or tear duct infections History of dry eyes Received chemotherapy in the last 6 months medical conditions which would prohibit or compromise placement and retention of eyelash extensions

I allow permission for photos to be used on social media, for advertising and or training purposes.

Yes No

I understand there are no refunds offered for services provided unless otherwise stated by the technician. *

Yes

I understand that payment is required in full at the end of the service provided. *

Yes

I understand that cancellations must be made with minimum 48 hour notice. If you have not arrived for your appointment and are 10 minutes late, your appointment is then considered a No Show Cancellation. All cancellations that do not provide sufficient notice will be charged for 50% of your booked service. No cancellation / no show will be responsible to pay 100% of the service fee, and must be paid prior to rescheduling. Please be mindful when needing to cancel or reschedule and let me know as soon as possible so Niš Beauty is able to accommodate clients on the waitlist. *

I accept the Cancellation policy described here

BY COMPLETING THIS CUSTOMER WAIVER AND LIABILITY AGREEMENT, I THE CLIENT NAMED HERE CERTIFY THAT I KNOWINGLY AND VOLUNTARILY RELEASE NIŠ BEAUTY AND ITS DIRECTORS, OFFICERS, OWNERS, EMPLOYEES, AGENTS AND REPRESENTATIVES FROM ANY AND ALL CLAIMS FOR DAMAGES OR PERSONAL INJURY ARISING FROM THE APPLICAION AND USE OF SEMI-PERMANENT EYELASH EXTENSIONS OR ANY OF THE OTHER ABOVE MENTIONED SERVICES AND PROCEDURES, INCLUDING ANY DAMAGES RELATING TO KNOWN OR UNKNOWN COMPLICATIONS WHICH MAY ARISE DURING OR FOLLOWING THE APPLICATION PROCESS INCLUDING BUT NOT LIMITED TO CLAIMS FOR NEGLIGENCE. I FURTHER RELEASE AND HOLD NIŠ BEAUTY FROM ANY CLAIMS RELATING TO PRE-EXISTING CONDIIONS I HAVE NOT REVEALED OR CHANGES TO THOSE CONDITIONS SUBSEQUENT TO THE PROCEDURE. *

Yes

I AGREE THAT ANY DISPUTES BETWEEN NIŠ BEAUTY SHALL BE SETTLED BY ARBITRATION ADMINISTERED BY THE ARBITRATION ASSOSIATION IN ACCORDANCE WITH ITS COMMERCIAL ARBITRATION RULES, AND JUDGEMENT ON THE AWARDED RENDERED BY THE ARBITRATOR(S) MAY BE ENTERED IN ANY COURT HAVING JURISDICTION THEREOF THE PREVAILING. PARTYS SHALL BE ENTITLED TO REASONABLE ATTORNEY FEES AND ABRITRATION COSTS INCURRED IN CONNECTION WITH ENFORCING THIS AGREEMENT. *

Yes

I certify that I have read and fully understand this Customer Waiver and Release Agreement. I further certify that I have completed the Client Confidential Profile accurately and completely to the best of my knowledge, and that I understand the complications and risks described herein. I herby authorize Niš Beauty and associates to provide and apply semi-permanent eyelash extensions or any of the above mentioned services or products, in accordance with the terms and conditions set forth in this agreement.

Signature

Clear

Lash Extension & Lash Lift