New Customer Registration Form - Eyelash Extensions

Ariyah Beauty

Online Eyelash Extension Consent Form
Full Name*

First NameLast Name
Appointment Date*

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
I consent to having a patch test prior to my appointment? Please understand - If you answer 'NO' unfortunately our professional eyelash extension technician can not proceed with the service.

YesNo
How did you hear about us?*
Is this the first time you have had eyelash extensions applied?

YesNo
Do you do any of the following with your lashes? (select those that apply)

CurlPermTintNone of the above
Do you wear contacts?

YesNo
Do you have or are you being treated for any eye illness or injury?

YesNo
Do you habitually rub, pull or pick your lashes for any reason?

YesNo
Are you able to keep your eyes closed for up to 2 hours?

YesNo
Please tick which of the following are applicable to you:*

Currently using any oil-containing sunscreen or moisturisers around the eyesCurrently using eye drops of any kind, prescription or over-the-counter (please list below)Any allergies or sensitivitiesHistory of an allergic reaction to eyelash extension productsHistory of recurrent eye or tear duct infectionsHistory of dry eyes or Sjorgen's SyndromeRecent history of ChemotherapyOther medical conditions which would prohibit or compromise placement and retention of eyelash extensionsNone of the aboveOther
Other*
I agree to have eyelash extensions applied to my natural eyelashes and/or removed and retouched. By signing this agreement, I consent to the placement and/or removal of the eyelash extensions by the Ariyah Beauty eyelash extension professional*

Yes I agreeNo I don't agree
I understand there are risks associated with having artificial eyelashes applied to and/or removed from my existing eyelashes, and that notwithstanding the utmost of care in the application or removal of these products, there still exists risks associated with the procedure and product itself, which include, without limitation, eye irritation, eye pain, discomfort and in rare cases, blindness when improperly handled. I also understand there is more than one technique for applying artificial lashes to my eyelashes, and I will not attribute any liability to the Professional or Ariyah Beauty as a result of this procedure or the use and care of these lashes. I also agree to defend, indemnify and hold harmless the Professional or Ariyah Beauty from any and all claims, actions, expenses, damages and liabilities, including reasonable solicitors’ fees which might be asserted against them as a result of my having this procedure performed, or my purchase of these Ariyah Beauty products.*

Yes I agreeNo I don't agree
I agree that if I experience any of these conditions (stated in the above section) with my lashes that I will contact the certified eyelash extension professional that performed this procedure and it may be beneficial to have the eyelash extensions removed.*

Yes I agreeNo I don't agree
I understand and agree to the after-care instructions provided by the certified eyelash extension professional for the use and care of my eyelash extensions. I realise and accept the consequences of failure to adhere to these instructions may cause the eyelash extensions to fall out and/or decrease the time the lashes will last and that Ariyah Beauty will NOT be held liable.*

Yes I agreeNo I don't agree
I understand and consent to have my eyes closed and covered for the duration of this approximately 120 minute procedure. Times may vary depending on the type and number of eyelashes applied*

Yes I agreeNo I don't agree
I understand and consent to have my eyes closed and covered for the duration of this approximately 120 minute procedure. Times may vary depending on the type and number of eyelashes applied*

Yes I agreeNo I don't agree
I agree to for the purpose of documentation, consent for photos to be taken, published and reproduced of my face, my eyes and /or eyelashes, both before and after this procedure, for any advertising.*

Yes to all the aboveNo I don't agreeYes but not for social media. For records only.
This agreement will remain in effect for this procedure and all future follow-ups conducted by the certified eyelash extension professional. I have read and understand that this consent agreement is legal and binding. I have read and fully understand all information in this agreement.
Clients Full Name*

First NameLast Name
Signature*

Powered by Jotform SignClear
Date of signed document*

MonthDayYear
Date
(If under 18) Parent/Guardians Full Name

First NameLast Name
Signature

Powered by Jotform SignClear
Date of signed document

MonthDayYear
Date
Should be Empty:

Ariyah Beauty