Eyelash Extension Consent & Waiver of Liability

Eyelash Extension Consent & Waiver of Liability
Name

First NameLast Name
Date of Birth

DayMonthYear
2 digit month, 2 digit day, 4 digit yearDate
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Have you had eyelash extensions before?
Do you currently have eyelash extensions on your lashes?
If yes, describe your set and experience level with eyelash extensions.
Example: Volume lashes, regular fills for the past 2 years.
Do you have any allergies?
If yes, please provide details:
If no, it is recommended to do a patch test. Please initial if you are opting out of the advised adhesive patch test. You acknowledge that a patch test does not guarantee an adverse reaction will not occur :
Please initial in acknowledgement that a patch test does not guarantee an adverse reaction will not occur.
Select the Lash Set you desire:
Select the Lash Style you desire:
Select the longest length you desire:
Please select all that applies to you:
What set are you interested in:
CLIENT WAIVER & RELEASE
Click all boxes to indicate that you have read each statement thoroughly and acknowledge, understand and agree to the following:

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.Release. I recognize that there are certain inherent risks associated with the above described treatment and assume full responsibility for injury to myself. In exchange for such treatment, I hereby fully release and forever discharge Bloom Beaute Studio LLC and Ashley Alvior (including members, owners, employees and agents) from any and all damages, costs, expenses, liabilities, causes of action, claims and demands, of character, in law or in equity whether known or unknown, direct or indirect, asserted or unasserted and whether or not on account of myself, Bloom Beaute Studio LLC, Ashley Alvior or other third parties, or in any way arising out of the above described service I have requested Bloom Beaute Studio LLC or Ashley Alvior perform. It is the intention of the parties that this agreement binds all parties whose claims may arise out of treatment or services provided by Bloom Beaute Studio LLC, Ashley Alvior including any spouse or heirs of the client/patient and any whether born or unborn. Any legal or equitable claim that may arise from participation in the treatment or service shall be resolved under Hawaii state law to indemnify, hold harmless and defend Bloom Beaute Studio LLC, Ashley Alvior (including its officers, members, owners, employees and agents) all third party claims, causes of action damages, judgments, costs or expenses, including attorneys' fees and other litigation costs, which may in arise from the above described treatment I have requested Ideal Bloom Beaute Studio LLC and Ashley Alvior perform.Arbitration It is understood that any dispute arising as to malpractice of the eyelash extensions service shall be decided by a neutral arbitrator. Any arbitration proceeding will be governed by Hawai’i arbitration statute, the fees for the arbitrator will be split pro-rata among the parties and each party will be responsible for their own attorneys' fees and costs. Any action to collect fees from the client/patient for the treatments performed brought in any court located in Hawai’i and the prevailing party in such collection action shall be entitled to recover its reasonable attorneys' fees and costs. Filing of any action in any court to collect any fee from the client/patient shall not waive the right to compel arbitration of any malpractice claim.
I understand there are risks associated with having artifical 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 risks associated with the procedure and product itself, which include, without limiation, eye irritation, eye pain, discomfort, and in rare cases, blindness even when applied in the usual manner.
As part of the removal procedure, I understand that a certain amount of chemical adhesive remover is applied to exsiting adhesives and a reaction occurs to dissolve the adhesive that results in 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 prevent damage to my eyes.
The agreement will remain in effect for this procedure and all future follow ups conducted by the certified eyelash extension professional. I read English and understand that this consent agreement is legal and binding. By sigining below, I have read and fully understand all information in this agreement and hereby release any and all persons representing this salon from all claims, demands, damages, actions and cause of action arising out of ther performance of the service. I have fully disclosed all condtions regarding my health history, medications and past reactions to products, treatments and medications. I am over 18 years of age and consent to the agreement and to the eyelash extension application procedure.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
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Eyelash Extension Consent & Waiver of Liability

CLIENT WAIVER & RELEASE