• LUXURY EYELASH EXTENSIONS

    INTAKE FORM

  • Contact Information

  • Date of Birth*
     - -
  • Gender:*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Would you like to be added to our email list for news and exclusive offers?*

  • MEDICAL HISTORY

  • Do you have or have you had any of the following conditions? If yes, please select them:*
  • Are you allergic to acrylic or latex? (Medical tape and adhesives required for eyelash extensions may contain acrylic or latex.)*
  • Do you have any other allergies?*
  • Do you have, or are you being treated for any eye illness or injury?*
  • Are you pregnant or could you be pregnant?*
  • Do you wear glasses?*
  • Do you wear contact lenses? If yes, please do not wear them the day of your service.*
  • Do you often have eye irritation, itching or watery eyes?*
  • Date*
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  • EYELASH HISTORY AND CONTRAINDICATIONS TO TREATMENT

  • Is this your first time having Eyelash Extensions?*
  • If this is NOT your first time receiving eyelash extensions, please provide details that will help us customize your service. Are you or have you experienced any of the following when receiving eyelash extensions:*
  • What type of Style of Lash Extensions are you looking to have done?
  • What length do you prefer?
  • Do you use/or do any of the following to your lashes?*
  • How often do you wear Strip Lashes?*
  • Do you have extremely oily skin or hair? Natural oils will break down the adhesives used to bond the eyelash extensions to your natural lash causing the extensions to fall out quicker. This doesn’t mean your not a good candidate for eyelash extensions, merely it may just cause them to fall out quicker and lash fills may need to be every 1-2 weeks.*
  • Do you use any of the following products on your eyelashes?*

  • We would love for you to enjoy eyelash extensions as much as we do.


    But there are certain situations in which the treatment shouldn’t be performed and therefore we wont be able to do the treatment. These are called “Contraindications”.


    Contraindications are conditions or symptoms that restrict the service to go ahead. If you have one or more of the below conditions, we will need to re-assess whether we are able to do the eyelash extensions service:


    -Contagious or eye infection disorder eg. Conjunctivitis
    -Hypersensitive skin
    -Stye (an abscess filled with puss caused by staphylococcus bacteria)
    -Swelling of the eyes
    -Cancer
    -Herpes
    -Cuts or open wounds in the area
    -Epilepsy
    -Claustrophobia
    -Semi-Permanent makeup Eg. eyeliner (healed after 6 weeks)

    There are situations that might need a written medical clearance like chemotherapy within the last 6 months or laser eye surgery.

    LASH EXTENSIONS CANNOT BE APPLIED IF:

    You have had a past allergic reaction to lash extensions. Unfortunately this does happen, and is the number one thing we need to know if your booking an appointment with us. If you’ve experienced any swelling, unusual amounts of redness to your eyelids or itchiness with past lash extensions please let us know! Allergic reactions can be very uncomfortable, and usually worsen with repeated exposure. If you think you may be experiencing any symptoms of an allergic reaction, we’d strongly recommend that you visit a doctor or pharmacist as soon as you can.

    Please note: all semi-permanent eyelash glues (the ones used to apply eyelash extensions- not stick-on, temporary false lashes) contain a key ingredient called cyanoacrylate, which can be an allergen. Unfortunately, there is no glue that does not contain this product, and no ‘hypoallergenic’ glue for those who have had allergic reactions in the past. If there ever is, we will be the first to now about it.

    -You have evidence of eye inflammation, a style or an eye infection. Your eye area needs to be completely healthy for any treatment to be safely applied. Our stylist cannot work closely with any of these conditions for the health and safety reason, and any appointments should be delayed until all symptoms have ceased. We’d hate for you to be uncomfortable.

    -If you have had laser eye surgery in the past 3 months (a letter from a doctor us required)
    -Whilst they are considered safe for pregnant women, we highly recommend a patch test first (see below)

    Patch Test:
    MilaV Aesthetics LLC strongly recommends a patch test if you’re pregnant or have had any sort of irritation/ sensitivity with lash extensions in the past. If you’re pregnant and have not had lashes before, we would strongly recommend booking a patch test of our products several days before your appointment - though allergic reactions are common, they can be difficult to treat during pregnancy. Plus, we’d hate for you to experience any discomfort or distress during your pregnancy - we’re sure you’d have enough on your plate! We have a waiver available for pregnant clients if you’re confident that a patch test is not necessary.

    While an allergic reaction to eyelash extension glue is quite uncommon, it can still occur. It is recommended that a small amount of glue is applied to the clients lashes 48 hours before a full set of extensions are carried out.

    Please fill out and initial below to confirm your understanding. If there is any signs of redness, itching, swelling or blistering, return to have any traces of adhesive removed and don not proceed with the treatment.
    * Intial Here

  • Do you have any allergies or have ever had any allergies or reactions to eyelash extensions?*
  • Please consent or decline patch test:*
  • Date*
     - -

  • EYELASH EXTENSIONS CLIENT CONSENT FORM

  • I hereby consent to and authorize MilaV Aesthetics LLC and employees to perform the following procedure: Eyelash Extensions


    Although every precaution will be taken to ensure your safety and wellbeing before, during and after your lash extension application, please be aware of the following information and possible risks.


    -I understand that a full set of lash extensions can make the appearance of my own lashes about 30-50% thicker, and make my lashes appear 20-50% longer.

    -I understand that lash extension services have some inherent risk of irritation to the orbital eye area, including the eye itself, and could result in stinging and burning, blurry vision and potential blindness 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 in contact with it.

    -I understand that if the bonding agent comes in contact with my eye, my eye will be flushed with water and I will be assisted in seeking medical attention immediately.

    -I understand that this is a semi-permanent procedure, as my natural lashes will continue to grow and fall out normally, making touch-up or “fill” appointments necessary to maintain the original look achieved by replacing the lashes that have fallen out.

    -I understand that while every attempt will be made to provide me with the length and fullness I have chosen, my final result may not be what i initially envisioned.

    -I understand that it is imperative that i disclose all of the information requested in the client Intake form.

    -I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications.

    -I understand that additional conditions could occur or be discovered during the procedure which could affect my ability to tolerate the procedure.
    * Initial Here

  • I agree to the following eyelash extension follow-up and maintenance instructions:*

  • This agreement will remain in effect for this procedure and all future follow-ups conducted by the licensed eyelash extension professional. I understand my lash extensions specialist will take every precaution to minimize or eliminate negative reactions as much as possible. I will hold him/her and his/her staff harmless and nameless from any liability that may result from this treatment. 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 the day of service. I have read and fully understand all the information in this agreement. I am over 18 years of age and consent to the agreement and to the eyelash extension application procedure.

    * Initial Here

  • Date*
     - -
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  • PHOTO & VIDEO

    RELEASE FORM

  • I, * hereby grant and authorize MILAV AESTHETICS LLC the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures, videos and/or audio taken of me to be used in and/or for any lawful promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, press kits, websites, social media sites and other print and digital communications, without payment or any other consideration.

    This authorization shall continue indefinitely and extends to all languages, media, formats and markets now known or later discovered.

    I waive any right to royalties or other compensation arising or related to the use of the photograph or recording.

    I understand and agree and agree that these materials shall become property of MILAV AESTHETICS LLC and will not be returned.

    I hereby hold harmless and release MILAV AESTHETICS LLC from all liability, petitions, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons may make while acting on my behalf of my estate.

    By signing below, i hereby acknowledge that I have completely read and fully understands the above release agreement.

  • Date*
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  • CANCELLATION, TARDY AND NO SHOWS POLICY

    PLEASE READ CAREFULLY

  • Cancellation Policy:
    Our goal to provide quality care in a timely manner. In order to do so, we have had to implement an appointment/cancellation policy.

    Appointments are in high demand, and your early cancellation will give another person the opportunity to have access to timely care. This policy enables us to better utilize available appointments for our clients.

    When making a booking, it is necessary to provide a valid credit or debit card to secure your appointment. To ensure the appointment is secured, a non-refundable booking fee must be paid. Rest assured that your card information will be kept confidential. Once your service is finished, you have the choice to pay using the card on file, zelle or with cash. If you opt for card payment, a 2.6% processing fee will be added. If you need to cancel or reschedule your appointment, please provide a minimum of a 3-day notice. A reminder will be sent 24 hours prior to your scheduled appointment time. However, cancelling after the 24-hour reminder will result in a cancellation fee equivalent to 100% of the remaining service cost.

    Tardy Policy:
    By arriving late, you may inconvenience other clients who arrive punctually. Clients are given a 10-minute grace period, but if you exceed this timeframe, you will receive notifications via text and email informing you that your appointment has been cancelled. The deposit you made cannot be refunded and cannot be transferred for future use. If you wish to reschedule, you will need to submit a new non-refundable deposit when booking a new appointment. Each client is afforded only two opportunities to adhere to these policies. Failure to comply will result in being barred from booking any future appointments.

    NO SHOWS:
    Please note that in the event of a no-show, the paid booking deposit cannot be refunded and cannot be transferred to another appointment. Your failure to show up for your scheduled appointment prevents other clients from utilizing that time slot for their own services. However, in cases of no-shows, your credit card on file will be charged for the remaining 100% of the service fee, along with a 2.6% processing bank fee.

    I have read and understand the above Appointment Cancellation, Tardy, and NO SHOW Policy and agree to be bound by its terms. I agree to pay the cancellation fee in the event of a missed appointment.

    *Initial Here

  • Date*
     - -

  • CREDIT CARD AUTHORIZATION

  • I give my consent for MilaV Aesthetics to make a payment using my card. I acknowledge that while this data is stored securely in a protected online client file, there is a small possibility of it being compromised. I agree to bear the responsibility if the file and credit card details are accessed without authorization. I also agree to reach out to MilaV Aesthetics for help or clarification if I have any doubts or inquiries about charges made to my account, or if a payment fails to be recorded. I acknowledge that I will not challenge any charges through my credit card provider unless I have first made an effort to resolve the issue directly with MilaV Aesthetics and those efforts have proven unsuccessful. I comprehend and consent to these terms. I comprehend the terms of this payment policy and consent to the aforementioned conditions.

    * Initial Here

  • Date*
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  • LIFESTYLE

  • Select any of the following activities in which you participate in:*
  • How do you usually sleep? Please be aware that you will lose more eyelash extensions on the side of which you sleep. Sleeping on your stomach will affect them the most.*
  • How often do you wear makeup?*
  • What does your makeup and skincare routine consist of?*

  • EYELASH EXTENSIONS ARE SUCH A GAME CHANGER!!

    Here is what to expect the day of your appointment.

  • STEP 1: - You will consult with your lash artist to insure this service is right for you. Your lash artist will go over before, during and after care instructions with you before starting your service. Please come in to your appointment with a bare clean face.

    STEP 2: - You will select the style of lashes you would like. We will discuss Length, fullness and shape. If you’re unsure, your lash artist will be happy to recommend what’s best for you and your daily lifestyle.

    STEP 3: - Will we then get started with a lash bath and ensure that your lashes are free of any oils or debris that may affect retention. Your bottom lashes will be taped down and application will then begin.

    STEP 4: - GET LASHED! The whole service should be pain free and comfortable. If at any moment you start to feel burning, poking or itching be sure to let your lash artist know as soon as possible.

    STEP 5: - Admire your new gorgeous LASH SET! Please be sure to address any issues or concerns with your lash artist before leaving your appointment. If there is anything you are unhappy with or wish to change this will be the perfect time to speak up. Once you walk out the salon your appointment will be over and i will not be able to address any concerns you may have. All sales are FINAL.

    STEP 6: - LADIES PLEASE PRE-BOOK YOUR LASH FILLS BEFORE LEAVING THE SALON. APPOINTMENT TIMES ARE LIMITED!! FILLS ARE HIGHLY RECOMMENDED EVERY 2-3 WEEKS!!
    * Initial Here

  • Date*
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