Lash Procedure Consent & Intake

Date

Name

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

Read the following statements before signing.

I agree to have eyelash extensions applied to my natural eyelashes and/or remove and retouched. By signing this agreement, I consent to the placement and removal of the eyelash extensions by the certified eyelash extension specialist.

I understand that there are risks associated with having eyelash extensions applied to or removed from my natural eyelashes. I further understand that as part of the procedure, eye irritation, eye itching, and in rare cases, an eye infection can occur. I understand that if I experience any of these conditions with my lashes, I will contact the certified lash professional and have the extensions removed immediately at no cost to me, and I will consult with a physician at my own expense. I understand that even though the certified eyelash extension professional applies or removes the eyelashes using the proper technique, the instruments, tapes, cleansers, eye pads, adhesives and removers used may irritate my eyes or require a physician's follow-up care.

I understand and agree to the after-care instructions provided by the eyelash extension professional. I realize and accept the consequences of failure to adhere to these instructions, as it may cause the eyelash extensions to fall out prematurely, cause natural lash damage, and/or decrease the time the lashes will last. These after-care directions include: Do not use mascara. Do not use sunscreens, oil based products or oil based removers around the eyes. Keep your lashes dry for the recommended 24 hours. No picking, pulling, or rubbing your extensions. Do not curl or trim your lashes. Keep your lashes clean, dry and brushed.

I understand that if I have any concerns, I will address these with my certified lash extension specialist. I give permission to my certified lash extension specialist to perform the lash extension procedure we have discussed, and will hold her harmless and nameless from any liability that may result from this treatment. I have accurately signed to all of the statements above the questions above. I understand my lash extension specialist will take every precaution to minimize or eliminate negative reactions as much as possible. In the event that 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, whose signature appears below, 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.

Do you experience allergies?

YesNo

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

YesNo

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

YesNo

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.

YesNo

I understand mascara will interfere wit the adhesive bond with disastrous results.

YesNo

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.

YesNo

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.

YesNo

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.

YesNo

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

YesNo

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

Current use of contact lensesCurrent use of eye drops of any kind, prescription or over-the-counterCurrent use of oil based products such as sunscreen, moisturizer, face wash and make-upHistory of recurrent eye or tear duct infectionsHistory of dry eyesReceived chemotherapy in the last 6 monthsMedical 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.

YesNo

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

BY COMPLETING THIS CUSTOMER WAIVER AND LIABILITY AGREEMENT, I THE CLIENT NAMED HERE CERTIFY THAT I KNOWINGLY AND VOLUNTARILY RELEASE GIGI LASH EXTENSIONS LLC AND ITS DIRECTORS, 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 GIGI LASH EXTENSIONS LLC FROM ANY CLAIMS RELATING TO PRE-EXISTING CONDITIONS I HAVE NOT REVEALED OR CHANGES TO THOSE CONDITIONS SUBSEQUENT TO THE PROCEDURE.*

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 Gigi Lash Extensions LLC 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

Lash Procedure Consent & Client Intake