Clone of Eyelash Extensions Consent Form

1
Full Name* This field is required.
First Name
Last Name
2
Your Suburb and Post Code* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
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3
Phone Number
Please enter a valid phone number.
4
E-mail* This field is required.
example@example.com
5
Date of birth* This field is required.
DD/MM/YYYY
6
How did you hear about us?* This field is required.
Google
Social media
Word of mouth
Passing by
Others (Please specify...)
7
How did you hear about us? Others (Please specify...)
8
Is this the first time you have had eyelash extensions applied?* This field is required.
YESNO
9
If this is not your first time getting lash extensions, where and when have you had them applied?
Please type salon name and your last appointment date with them
10
Which style of lashes do you prefer?* This field is required.All lash styles can be created with Individual (Classic) or Russian Volume lashes. We will take a note of your preference, however your lash artist today will assess the condition of your natural lashes and give suggestion on which style is best suited for your eye shape and natural lashes. Doll eye : short in both corners and longest in the middle of your eye Natural eye : short in both corners and longest in the 3/4 of your eye Cat eye: short in the inner corner, longer in the middle, and longest in the outer corner of your eye Extreme cat eye: short in the inner corner all the way to the 3/4 of your eye, and then longest in the outer corner of your eye
Doll eye
Natural eye
Cat eye
Extreme Cat eye
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Doll eyeShort in both corners and longest in the middle of your eye
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Natural eyeShort in both corners and longest in the middle of your eye
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Cat eyeShort in the inner corner, longer in the middle, and longest in the outer corner of your eye
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Extreme cat eyeShort in the inner corner all the way to the 3/4 of your eye, and then longest in the outer corner of your eye
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What length of extensions would you like have today?* This field is required.We take a note of your preference, however your lash artist today will assess the condition of your natural lashes and determine which length is suited best for your eye shape and natural lashes.
Short
Medium
Long
16
Have you had any previous issues / allergy with eyelash extensions in the past?* This field is required.
YESNO
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What is your previous issues / allergy with eyelash extensions in the past?* This field is required.
Please be as clear as possible
18
I understand that I had issues in the past with eyelash extensions (including allergic reaction) and will proceed with the appointment today using Sensitive glue - knowing the full risk of potential irritation that may arise from lash application. This has been communicated to me by my lash technician. I am fully responsible for my own action and will not hold Mollylash and its representative legally accountable.
YESNO
19
Permission to use pictures* This field is required.I hereby grant my service provider the full right to take, publish and reproduce photographs of me, my face, my eyes and/or eyelashes, both before and after the procedure, for any advertising, education, or other purposes whatsoever.
YESNO
20
Waiver of liability* This field is required.I agree to having artificial eyelashes applied to and/or removed from my natural eyelashes. I understand that there are rare risks associated with the procedure such as eye irritation, allergic reaction, and discomfort could occur. I agree that if I experience any of these conditions with my lashes that I will contact my GP for medical assistance and my lash artist for a removal - and my lash artist will only if it has been advised by the GP to safely remove. Whilst proper techniques and procedure will be performed by the lash artist, the instruments, tapes, cleansers, eye gel pads, adhesives, removers, tint, waxes, eyelash lift and other product use may irritate my eyes. I further agree that I will not hold Mollylash or any of its employees responsible should there be any unfavourable result. I acknowledge and consent to the use of CCTV cameras with microphones in the reception area for the purposes of quality assurance and training. I understand that these recordings are used to enhance service quality and for staff training purposes. Please note that no refund will be given under any circumstances.
YESNO
21
Care and maintenance* This field is required.I agree to follow the care and maintenance instructions provided to me by my lash artist, 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 not do any of the following, it may compromise on the retention of lash extensions and damage my natural lashes: 1. I agree to avoid oil based eye products as these will loosen the bond of my eyelash extensions 2. I agree to avoid mascara (on top and bottom lashes), gel eyeliner and heavy eye makeup, as well as an eyelash curler, perm, or tint on my eyelash extensions. I understand that if my eyelash technician is not able to clean my extensions thoroughly during refill appointment due to make up buildup, a removal and full set will be performed on that appointment and there will be an increase in service fee. 3. If I experience any itching or irritation, I agree to contact my GP to have a medical written letter to advise us to have the lash extensions removed. 4. I agree not to pick, pull or rub my eyelash extensions 5. I understand that I should not attempt to remove or cut my eyelash extensions on my own, but to have them professionally removed CONTINUE TO PART 2
YESNO
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Care and maintenance part 2* This field is required.I understand that if I do not do any of the following, it may compromise on the retention of lash extensions and damage my natural lashes: 6. I agree to avoid getting my lashes wet within 24 hours after application 7. I agree to avoid steam, saunas, and swimming within 2 days of application 8. I understand that I need to use MOLLYLASH Lash Shampoo to clean my lashes daily so its free from bacteria, oil, and make up buildup 9. I understand that refill prices are only applicable if the refill appointment is booked less than 4 weeks apart and if there is still 50% of lashes remains attached. I understand that I will have to book in for a removal and full set if the appointment booked has lapsed for more than 4 weeks, or if I have less than 50% of lash extensions remains attached. 10. I understand that a removal and new set is highly recommended after I have completed 4 refills in a row. Removal is needed for lash technician to be able to deep clean the natural lashes and therefore it will improve lash retention in the future. Please refer to our Mollylash aftercare Youtube video for more information about aftercare
YESNO
23
No Known Medical Conditions / Informed Consent* This field is required.I have read and completed the Client Consent Form in its entirety and in truth. I understand that I need to disclose any allergies that I may have to synthetics, cyanoacrylate or formaldehyde which in small amounts may be present in the adhesive. I understand that the procedure requires that I lay still with my eyes closed. 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 instructions or these warnings. This Agreement will remain in effect for this procedure, and all future procedures.
YESNO
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Signature* This field is required.I agree that this Agreement is binding upon me, and my heirs, legal representatives and assigns. I represent that I am at least 18 years of age and that I have the right to enter this agreement.
I am over 18 years old
I am under 18 years old
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Signature of legal guardian* This field is required.I agree that this Agreement is binding upon me, and my heirs, legal representatives and assigns. I am under 18 years of age and I have my parent or legal guardians consent to this agreement.
Clear
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Signature* This field is required.I agree that this Agreement is binding upon me, and my heirs, legal representatives and assigns. I represent that I am at least 18 years of age and that I have the right to enter this agreement
Clear
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You have to agree to our terms and conditions before services can be provided to you
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