Lash Extension Client Consultation & Consent Form

Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
When is your birthday

MonthDayYear
This isn't mandatory, but who knows you might get a birthday gift!
Tell us a bit about yourself, I love to get to know my clients to give you the best possible service
Don't worry if you can think of anything right now, I'm sure we will get to know each other soon!
Have you previously had lash extensions before?

YesNo
If so, did you have any reactions or discomfort during / after the procedure? Please explain.
Have you had any recent eye infections? If so, please tell us what happened and when.
In the last 72 hours have you had any eye irritation or discomfort? If so, please tell us what happened and when.
Please tell us if you are currently taking any medications (including any non-prescription)?
As above, Please tell us if you are on any thyroid or hormonal medications?
Have you had any recent eye surgery or laser eye surgery?
Do you wear contacts or have any eye issues? If yes, please specify:
Eye contacts should be removed before appointment for safety
Do you have any general allergies or sensitivities? If yes, please specify:
Do you have any allergies with essential oils, candles or reed diffusers, cats and/or dogs?*
There won't be any animals in the room but there are cats and a dog in the house ♡
Do you have or have you had in the past 2 weeks any of the following;

Viral infections such as herpesEczemaOveractive or underachieve thyroid gladsAlopecia AreataMadarosis / MilphosisRecently undergone ChemotherapyStyesBlepharitiesNone of the aboveOther
What are your expectations for this appointment?
Do you have a favourite style/set of lashes? Looking to try something new? Or completely new to the lash world?
At Amora Beauty we provide silent lash appointments with calm relaxing music, Please let me know below if you would like to listen to anything else.
This is so I can give you the best service possible and ensure you are comfortable at all times!
Any preferences to your appointment?

Silent appointment (Time to unwind and relax)I'll bring something to listen toI'll fall asleepRelax and chatOther
CLIENT WAIVER AND AGREEMENT
I your name* agree to have eyelash extensions applied to my natural eyelashes and/or removed and retouched. By signing this agreement, I consent to the placement
and/or removal of the eyelash extensions by the certified eyelash extension professional.
I your name* understand that in rare occasions there are risks associated with having artificial eyelashes and eyelash extensions applied to or removed from my natural eyelashes. I further understand that in rare cases as part of the procedure eye irritation and discomfort could occur. I agree that if I experience any of these conditions with my lashes that I will contact the certified eyelash extension professional that performed this procedure and it may be beneficial to have the eyelashes removed and in some extreme cases due to allergy to advise with your doctor.
*Keeping in mind allergic reactions can happen at any time whether you've had extensions before or not. You agree to go ahead with the service and understand there can be complications which is out of your lash technicians hands.
I your name* understand that if I have mentioned to having any previous reactions and/or complications or anything that my technician sees as being a possible risk, I may be
requested to have a patch test 24hrs before the full application to ensure I will not have any further risks with this application or any further applications from my technician/salon (name of
technician/salon) Amora Beauty*
I your name* understand and agree to the after-care instructions provided by the certified eyelash
extension professional for the use and care of my eyelash extensions. I realize and accept the consequences of failure to adhere to these instructions may cause the eyelash extensions to fall out and/or decrease the time the lashes will last.
I your name* understand and consent to having my eyes closed for the duration of approximately 1 to 3 hour procedure. Times may vary depending on the type and number of eyelashes applied. I also agree to lie still for the entire procedure for safety reasons. If you feel uncomfortable at any time during the procedure, then please tell your lash technician
immediately.
I your name* agree to the following eyelash extension follow-up and maintenance instructions:
- No waterproof mascara
- No oil based products around the eye area
- No HOT water or steam can come into contact with the eye area for 24 hours after application
- No tinting or perming of the eyelash extensions
- No excessive rubbing or any pulling of the eyelash extensions
I your name* understand that because of the natural lash cycle and wear and tear, I will need to
maintain my extensions with refill appointments usually recommended every 2-4 weeks.
I your name* give consent for photos to be taken of my lashes and used for the salons purpose. This includes on social media/portfolio.
Yes No*
I understand there are risks associated with having artificial eyelashes applied to and/or removed from my existing eyelashes, and that not with standing the utmost of care in the application or removal of these products, there still exist risks associated with the procedure and product itself, which include, without limitation, eye irritation, eye pain, discomfort, and, in rare cases, blindness even when applied in the usual manner.

As part of the removal procedure, I understand that a certain amount of chemical adhesive remover is applied to existing adhesives and a reaction occurs to dissolve the adhesive that results in the thinning of the remover. Even though the eyelash extension artist may apply or remove my eyelash extensions in the usual manner, I understand the liquid remover may seep into my eyes, which may irritate my eyes or require further follow-up care, at my own expense to prevent any damage to my eyes.

This agreement will remain in effect for this procedure and all future follow-ups conducted by the certified eyelash extension professional. I read English and understand that this consent agreement is legal and binding. I have read and fully understand all information in this agreement. And hereby release any and all persons representing this salon from all claims, demands, damages, actions and cause of action arising out of the performance of the service.

Product purchases: I agree and understand that if I am purchasing a product from Amora Beauty they hold no liability if you have a reaction to the product. Amora Beauty does not create these products, and I understand and take it upon myself to purchase and use these products. (Skin cream, tanning products etc)

I have fully disclosed all conditions regarding my health history, medications and past reactions to products, treatments and medications.

I am over 18 years of age and consent to the agreement and to the eyelash extension application procedure.
Anything else you would like to add to your form?
Likes, Dislikes, Questions? Go for it!
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