Lash Service Client Application Form

Client Evaluation Form
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Date

MonthDayYear
Date
Health History - please list any allergies (inc. Cosmetic ingredients) or relevant medical conditions ? (Include any medications used)
Are you allergic to acrylate/cyanoacrylate (bonding agent) ?
Disclaimer

Although every precaution will be taken to ensure your safety before, during and after your procedure, please be aware of the following potential risks and information;
I understand that lash extension, lash lift and lash tint services have some inherent risk of irritation to the orbital eye area, including the eye itself, and could result in stinging and burning, blurry should the adhesive enter the eye or should an allergic reaction occur.
I understand that some irritation, itching or burning may occur on the skin if the bonding agent comes into contact with it.
I understand that this is a semi-permanent procedure, as my natural lashes will continue to grow and fall out normally, making touchup or “fill” appointments necessary to maintain the original look achieved by replacing the lashes that have fallen out. Most clients require a fill appointment every 2-3 weeks
I understand & agree to the aftercare instructions provided by the certified eyelash professional for the use & care of my eyelash extensions. I understand that if I request application of eyelash extensions beyond the recommended application advice by the certified extensions professional. I do so at my own risk. I realize & accept the consequences of faultier to adhere to these instructions may cause damage to my own natural lashes & cause the eyelash extensions to fall out and/or decrease the time the eyelash extensions will last
I consent to “before and after” pictures for the purpose of documentation, potential advertising and promotional purposes.
I understand that if I have any concerns, I will address these with my technician. I give permission to my technician to perform the lash extension procedure we have discussed, and will hold him/her and his/her staff harmless and nameless from any liability that may result from this treatment. I have accurately answered the questions above, including all known allergies, prescription drugs, or products I am currently ingesting or using topically. I understand my lash extension specialist will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult the lash extension specialist immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the lash extension specialist responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today.
This agreement will remain in effect for this procedure & all future follow ups conducted by the certified eyelash extension professional listed: Tien Huynh. I read & understand that this consent agreement is legal & binding. I read fully and understand all information in this agreement: I am over 18 years of age and consent to this agreement and to the eyelash extension application procedure
Signature
Should be Empty:

Client Evaluation Form

Disclaimer