You can always press Enter⏎ to continue
New Customer Registration and Consent Form
Combination: Eyelash Extensions and Brow Styling
START
1
Full Name
*
This field is required.
First Name
Last Name
Previous
Next
Submit
Press
Enter
2
Address
*
This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Previous
Next
Submit
Press
Enter
3
Phone Number
Please enter a valid phone number.
Previous
Next
Submit
Press
Enter
4
E-mail
*
This field is required.
example@example.com
Previous
Next
Submit
Press
Enter
5
Date of birth
*
This field is required.
DD/MM/YYYY
Previous
Next
Submit
Press
Enter
6
How did you hear about us?
*
This field is required.
Google
Social media
Word of mouth
Passing by
Others (Please specify...)
Google
Social media
Word of mouth
Passing by
Others (Please specify...)
Previous
Next
Submit
Press
Enter
7
How did you hear about us? Others (Please specify...)
Previous
Next
Submit
Press
Enter
8
Is this the first time you have had eyelash extensions applied?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
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
Previous
Next
Submit
Press
Enter
10
Which style of lashes do you prefer?
*
This field is required.
All 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
Previous
Next
Submit
Press
Enter
11
Doll eye
Short in both corners and longest in the middle of your eye
Previous
Next
Submit
Press
Enter
12
Natural eye
Short in both corners and longest in the middle of your eye
Previous
Next
Submit
Press
Enter
13
Cat eye
Short in the inner corner, longer in the middle, and longest in the outer corner of your eye
Previous
Next
Submit
Press
Enter
14
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
Previous
Next
Submit
Press
Enter
15
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
Previous
Next
Submit
Press
Enter
16
Have you had any previous issues / allergy with eyelash extensions in the past?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
17
What is your previous issues / allergy with eyelash extensions in the past?
Please be as clear as possible
Previous
Next
Submit
Press
Enter
18
Would you like to get brow styling done today as well?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
19
Please tick any of the following that applies to you:
Laser skin resurfacing
Taking antibiotics
Face Sunburnt
Diabetes
Face tan
Use of retinoid for skin treatment
Chemical Peel /Microdermabrasion
Hormonal imbalance
Alopecia
Pregnancy
Allergies to tint / henna / dye
Sensitive / dehydrated skin
Other
Previous
Next
Submit
Press
Enter
20
Precautions and Considerations for brow styling
*
This field is required.
1. You must wait a minimum of seven (7) days before waxing after a light chemical peel or microdermabrasion 2. The potential for skin reactions and/or lifting is likely when the skin is manually exfoliated 7 days prior to waxing, such as home microdermabrasion scrubs 3. Waxing shouldn't be performed if you have had laser skin resurfacing within the past year 4. Waxing shouldn't be performed if you have had a physician administered peel within the past year 5. Women may experience sensitivity to waxing up to a week prior and during their period 6. Sunburnt, extremely tanned or irritated areas cannot be waxed 7. Thin, fragile, dehydrated or sensitive skin may burn, tear or bruise from waxing procedures 8. Diabetics have a hard time healing, when a wound or lesion occurs to the skin, there may be complications 9. Allergies to any of the ingredients in the wax and/or pre and post wax products may cause severe allergic reaction. This may include inflammation, redness, itchiness, and potentially skin lifting 10. Pregnancy may cause discolouration to the hair once tinted due to hormonal changes
I confirm that I have read the precautions and considerations mentioned above and would like to proceed with brow styling service today
YES
NO
Previous
Next
Submit
Press
Enter
21
Is this the first time you have had brow styling?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
22
If this is not your first time getting brow styling, where and when have you had them applied?
Please type salon name and your last appointment date with them
Previous
Next
Submit
Press
Enter
23
Would you like to have dye / henna applied today?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
24
Which brow dye would you like to choose?
*
This field is required.
Regular brow dye and henna brow colour are both semi-permanent. The skin staining from regular brow dye will fade within 1-3 days, with the dye on the hairs lasting up to 2-3 weeks. With henna brows, you're looking at up to 1 week for the skin stain, and up to 4 weeks for the staining on the hairs.
Regular brow dye
Henna
Previous
Next
Submit
Press
Enter
25
Which dye colors do you prefer?
*
This field is required.
Black
Graphite
Blue Black
Chestnut
Light Brown
Classical Brown
Dark Brown
Previous
Next
Submit
Press
Enter
26
Which henna colors do you prefer?
*
This field is required.
Pearl Blonde (Blonde 1)
Light Blonde (Blonde 2)
Light Chestnut (Blonde 3)
Neutral Brown (Brown 1)
Cold Toffee (Brown 2)
Rich Taupe (Brown 3)
Graphite
Amber
Previous
Next
Submit
Press
Enter
27
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, my eyelashes and/or brows, both before and after the procedure, for any advertising, education, or other purposes whatsoever.
YES
NO
Previous
Next
Submit
Press
Enter
28
Waiver of liability
*
This field is required.
I agree to having artificial eyelashes applied to and/or removed from my natural eyelashes. I agree to having my eyebrows waxed (and tint/henna) applied to it. 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 lash artist for an emergency removal, or for severe reaction, seek immediate medical attention. Whilst proper techniques and procedure will be performed by the lash and brow artist, the instruments, tapes, cleansers, eye gel pads, adhesives, removers, tint, waxes, henna, and other product use may irritate my eyes and skin. 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.
YES
NO
Previous
Next
Submit
Press
Enter
29
Eyelash extensions 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 service provider immediately 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
YES
NO
Previous
Next
Submit
Press
Enter
30
Eyelash extensions 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
YES
NO
Previous
Next
Submit
Press
Enter
31
Brow styling care and maintenance
*
This field is required.
WITHIN 48 HOURS
Keep your brows dry and avoid contact with water. Avoid sweating excessively or use oil based make up remover on your brows. After 48 hours, you may swim, shower, and exercise as per normal
WITHIN THE FIRST WEEK
Avoid steam rooms, saunas, and steam facials
GENERAL CARE
1. When cleansing face thereafter, wipe around the brow area, avoid excessive cleansing or exfoliating the brow 2. When swimming apply oil or barrier cream to prevent premature lightening 3. Avoid applying resurfacing serums 4. Please note during the first 24 hours the henna or dye stain will develop into a darker colours as it reacts with the keratin of the skin. It will lighten gradually day by day
CONFIRMATION
I understand that tint/henna brows is temporary and potentially staining my skin for up to 2 weeks (tint) and 4 weeks (henna), and will fade as soon as 24 hours after the procedure is complete. I understand the result varies for everyone and overall skin and brows conditions and after care will ultimately affect the retention of brow tint/henna result. I agree to follow the maintenance instruction provided to me by my technician, 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.
YES
NO
Previous
Next
Submit
Press
Enter
32
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.
YES
NO
Previous
Next
Submit
Press
Enter
33
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
Previous
Next
Submit
Press
Enter
34
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
Previous
Next
Submit
Press
Enter
35
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
Previous
Next
Submit
Press
Enter
36
You have to agree to our terms and conditions before services can be provided to you
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
36
See All
Go Back
Submit