Clone of Combination: Eyelash Extensions and Brow Styling Consent Form

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Full Name* This field is required.
First Name
Last Name
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Your Suburb and Post Code* This field is required.
Street Address
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Phone Number
Please enter a valid phone number.
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E-mail* This field is required.
example@example.com
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Date of birth* This field is required.
DD/MM/YYYY
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How did you hear about us?* This field is required.
Google
Social media
Word of mouth
Passing by
Others (Please specify...)
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How did you hear about us? Others (Please specify...)
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Is this the first time you have had eyelash extensions applied?* This field is required.
YESNO
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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
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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
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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
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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?
Please be as clear as possible
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Would you like to get brow styling done today as well?* This field is required.
YESNO
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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
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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
YESNO
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Is this the first time you have had brow styling?* This field is required.
YESNO
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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
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Would you like to have dye / henna applied today?* This field is required.
YESNO
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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
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Which dye colors do you prefer?* This field is required.
Black
Graphite
Blue Black
Chestnut
Light Brown
Classical Brown
Dark Brown
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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
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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.
YESNO
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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.
YESNO
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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
YESNO
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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
YESNO
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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.
YESNO
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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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