• Eyelash Extension

    Eyelash Extension

    Client Consent Form
  • Client Information
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  • 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”.
  • Do you wear glasses?
  • Do you have frequent eye irritation, itching, or watery eyes?
  • Have you had eye surgery in the last six months?
  • Eyelash extensions require medical tape and adhesives that may contain acrylic or latex.
  • Are you allergic to latex?
  • Are you allergic to any eyelash adhesive?
  • PLEASE CHECK ANY OF THE FOLLOWING THAT MAY APPLY TO YOU:
  • RELATING TO THE EYE
  • GENERALLY RELATING TO EYELASHES
  • Date
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  • Eyelash Extension

    Eyelash Extension

    Liability Waiver
  • Please initial:
  • 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 with no intention to reschedule your appointment will incur a 100% charge of your service * If you fail to show up on your scheduled appointment time that would be considered a no show. No shows will also incur a 100% charge of your service.

  • Late Policy * Please let me know in advance if you are running late. If you are going to be 10 minutes + late there will be a $15.00+ fee. 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).

    * After 15 minutes, your appointment will be canceled and you will lose your deposit.

  • Deposit & Rescheduling Policy
    A $50 deposit will be charged to the card on file at the time of booking to secure your appointment. This deposit is non-refundable.

    If you reschedule your appointment on the same day it is scheduled to take place, your original deposit will be forfeited, and a new $50 deposit will be required to book your rescheduled appointment.

    If you cancel your appointment within the required cancellation timeframe and wish to transfer your deposit to a rescheduled appointment, the new appointment must be scheduled within 72 hours of the time you cancel.


    If a new appointment is not scheduled within 72 hours, the deposit will no longer be eligible for transfer and will be forfeited. Deposits are non-refundable and cannot be held indefinitely.


    Same-day rescheduling affects my ability to fill your original time slot, potentially preventing another client from booking and resulting in a loss of income. I kindly ask that you respect my time and schedule accordingly.

  • Squeeze In & After Hour Appoinment Policy

    Couldn’t find a time slot on my calendar that fits your needs within my business hours. Please feel free to reach out, and we can coordinate a time that works for both of us. There is a small fee of $15 for SQUEEZE IN appoinments if applicable.

    My business hours are Monday through Friday, 9:00 AM to 5:00 PM.

    If you require an appointment outside of these hours, there is a small fee of $30.00 to accommodate you. Please let me know if you’d like to schedule a time outside of my regular hours, and I will be happy to assist.

  • 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.  I understand that my esthetician is not left acountable for any medical bills. I understand all the risk that may occur when get eyelash extentions.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. 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.

  • 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.
  • 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.
  • 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.
  • Refund Policy- I understand that i will not be receiving a refund at anytime. 

  • Date
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  • I * have read everything
    thoroughly and understood all policies.

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