EYELASHES EXTENSION AGREEMENT AND CONSENT FORM

EYELASHES EXTENSION AGREEMENT AND CONSENT FORM
Name
Birth Date

MonthDayYear
Date
Age
Address

Address

Street Address Line 2

CityState

Zip
Phone
Email
example@example.com
Emergency Contact
Referred by
Shape
Curl
Length
Have you ever had eyelash extension before?
If yes what type?
Cluster, individual, strip lashes
If NO, we recommend a patch test. Please initial if you are opting out of the advised adhesive patch test. YES, I will take the advised adhesive patch test NO, I will not take the advised adhesive patch test*
Please CHECK BOX

I understand patch test does not guarantee that an adverse reaction will NOT happen.
Have you been using any eyelash conditioner?
YES or NO
If YES, what brand?
Did you have any allergies or allergic reaction?
YES or NO
If YES, please explain
Is there any medical reason why eyelash extension may not be suitable for you?
YES or NO
If YES, please explain
IF ANY OF THE FOLLOWING APPLIED TO YOU IN THE PAST 6 MONTHS, PLEASE CHECK

Allergy to adhesive in band aid or medical tapeSeasonal AllergiesEye illness or injuryBlepharitisInflamed eyelidsAllergy to surgical glue or nail glueMetal tools
Health Conditions:

NormalPregnanton medicinesensitive skin
Please list any medical conditions or medications you are currently on
We would like your permission to use these photos/videos for advertising. For example, in portfolios, online and in print adds, ect. Your consent is necessary regarding this. Please circle and indicate with your signature if you would like your photos/video used or not used in advertising.
Photos will be taken regardless for insurance purposes
Please read and understand all the information listed below and sign the form prior to having this service preformed.

I understand that this procedure requires single synthetic eyelashes to be glued to my own natural eyelashes. I understand that it is my responsibility to keep my eyes closed and be still during the entire procedure, until my eyelash technician addresses me to open my eyes. I understand that some risks of this procedure may be but are not limited to eye redness, swelling of eyelids and irritation. The fumes from the adhesive may cause my eyes to water if I open my eyes.I agree to disclose any allergies that I may have to latex, surgical tapes, cyanoacrylate, Vaseline, etc. I understand that I am required to follow the eyelash extension care sheet in order to maintain the life of these extensions. I agree and understand this entire consent form. I am of sound mind and fully capable of executing this waiver for myself.I agree if anything happens to my lashes, I will to contact my eyelash technician and/or the salon within 24 hours.I understand there will be no refund will be given for any services provided. There will be no charge for the removal if there is an allergic reaction. Eyelash extensions are not for everyone. This is a high-maintenance beauty treatment that requires gentle care for the lashes to remain in good condition and be long-lasting. Once the lashes are attached, I understand that I must not rub or pull on them. I must not wear any mascara other than that recommended by my eyelash technician. I must not use any lash curlers.I understand the natural growth cycle of an eyelash is 60-90 days. Each month approximately 30% of my eyelashes shed and extensions go with them. When one sheds another lash grows in. I understand that I will need touchups every 2-3 weeks to keep my lashes looking optimal. I understand that variables including my natural eyelash cycle and my home care regime will influence the longevity of my eyelash extension.I certify that I am in good health and have no allergies or medical condition that would prevent my participation in these services. Furthermore, I agree to use my personal medical insurance as sole and primary coverage payment if accident or injury occurs, due to any reason before or after my participation in any of these services.
Indemnification and Assumption of Risks.

(a) I understand these risks and know that my participation in these services may involve risk of inflammation, irritation, swelling, redness of the eyes/skin/face, or loss of lashes.(b) I understand that this waiver and release of liability is intended to address all of the risks of any kind associated with my participation in any aspect of these services, including particularly, such risks created by actions, inaction, carelessness, or negligence, gross negligence on the part of ………………………... I assume all risks, known and unknown, foreseeable and unforeseeable, in any way connected with my participation of such services. I accept personal responsibility for any liability, injury, loss, or damage in any way connected with my participation in these services.Waiver of Trial by Jury. I agree to waive my right to a trial by jury. Applicable Law. This instrument shall be governed, construed, and enforced in accordance with the laws of the State of Texas. My signature on this document is intended to bind not only myself but also my successors, heirs, representatives, administrators, and assigns.
I
Full name
HEREBY RELEASE, WAIVE, DISCHARGE, COVENANT NOT TO SUE,

AND AGREE TO HOLD HARMLESS FOR ANY AND ALL PURPOSES, LIABILITIES, CLAIMS, DEMANDS, INJURIES (INCLUDING DEATH), OR DAMAGES, INCLUDING COURT COSTS AND ATTORNEY'S FEES AND EXPENSES THAT MAY BE SUSTAINED BY ME WHILE PARTICIPATING IN THESE SERVICES, INCLUDING INJURIES SUSTAINED AS A RESULT OF THE SOLE, JOINT, OR CONCURRENT NEGLIGENT OR GROSS NEGLIGENCE, NEGLIGENCE PER SE, STATUTORY FAULT, OR STRICT LIABILITY OF

THIS IS A WAIVER AND RELEASE OF LIABILITY.
I
Full name
HAVE READ THIS WAIVER, RELEASE I OF LIABILITY, INDEMNIFICATION, AND STATEMENT OF PHYSICAL CONDITION. I UNDERSTAND THATI HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT.
Client Name (Print)
Client's Signature

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Client's Parent/Guardian Name:
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Date

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Date
For office use:
Technician Name
Signature

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