Eyelash Extension Consent Form

1
Name* This field is required.
First Name
Last Name
2
Phone Number* This field is required.
3
Email* This field is required.
example@example.com
4
Date Of Birth* This field is required.
Date
Month
Day
Year
5
Address* This field is required.
Street Address
Street Address Line 2
City
Texas
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The Gambia
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Nigeria
Niue
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Poland
Portugal
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Romania
Russia
Rwanda
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Other
Country
6
Preferred Language* This field is required.
English
Spanish
7
How did you hear about us?* This field is required.
Website
Web search
Google Map
Instagram
Facebook
Friend
Other
8
I grant permission to LASH ALE to use my before and after photos for marketing or as examples of my technician's work.* This field is required.
Yes
No
9
Have you ever had eyelashes extensions before?* This field is required.
Yes
No
10
If no, we would you like to have a patch test which we highly recommend? (Note that a patch test does not guarantee that an adverse reaction will never happen)* This field is required.
Yes
No
11
If yes, where have you had them applied and what brand was used?* This field is required.
12
Have you ever experienced an allergic reaction to eyelash extensions?* This field is required.
Yes
No
13
When was the last time you had an allergic reaction to eyelash extensions? * This field is required.
Date
Month
Day
Year
14
Do you have sensitive eyes?* This field is required.
Yes
No
15
Do you wear glasses or contacts?* This field is required.
Glasses
Contacts
Both
None
16
Do you wear makeup?* This field is required.
Yes
No
17
Do you wear Eyeliner?* This field is required.
Yes
No
18
Do you use lash growers such as Lattice or over the counter ones? It is best to discontinue use of these type of products 2 weeks before your service and discontinue use while you are wearing your lash extensions. Some contain oils/steroids and will shorten the duration of your extensions. There is eye-lash extensions approved products for your natural lashes that we can recommend while you have extensions.* This field is required.
Yes
No
19
Do you habitually rub, pull, or pick your eyelashes?* This field is required.
Yes
No
20
Which side do you predominantly sleep on?* This field is required.
Sides
Back
Stomach
21
Certain conditions may affect lash retention and growth, how frequently a fill may be required, and whether or not you are a good candidate for lash extensions.* This field is required.Please check for the following conditions that apply to you:
Glycerin allergy
Latex allergy
Allergy to adhesives band aid or medical tape
Allergy to surgical glue or nail glue
Seasonal allergies
Formaldehyde, cyanoacrylate, or any adhesive or glue allergy
Use of oral contraceptives
Pregnant
Childbirth within 120 days
Hormonal imbalance or extreme stress
Recent eye surgery
Retinoids (eg. Accutane, Retin A)
Recent stye
Chemotherapeutic agents
Iron deficiency
Lash lift, perm, or tint within 120 days
Dry eyes
Sensitive eyes
Watery eyes
Alopecia
Antibiotics
Claustrophobia
Thyroid diseases
Herpes Simplex (HSV-1 and HSV-2)
Eye illness or injury
Blepharitis (inflamed eyelids)
Permanent eye-makeup
Eye lift
Drugs that can cause temporary hair loss
Major surgery within last 120 days
None
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* This field is required.
23
Please go back* This field is required.If "None of the above" is selected, please ensure that no other options are selected
24
Any allergies or reactions?* This field is required.
Yes
No
25
If yes, what are your allergies or reactions?
26
Are there any eye medications or eye drops you are currently using?* This field is required.
Yes
No
27
If yes, what eye medications or eye drops are you currently using?
28
Any medical history concerning your eyes?* This field is required.
Yes
No
29
If yes, what is your medical history regarding your eyes?
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Are you allergic to adhesives (glues, tapes, band aids, etc)? This service may use adhesives tapes, glues and gel pads that may cause an allergic reaction. We use a medical grade, formaldehyde free glue, but allergies may still occur?* This field is required.
Yes
No
31
Have you had Chemotherapy treatments in the last 6 months? Medication for chemotherapy may cause a reaction to the materials used in this service. Also, if lashes are just starting to grow back they may be a little weak and we recommend waiting until they are strong enough for this service.* This field is required.
Yes
No
32
Are you currently taking Thyroid Medications? Thyroid medications or Thyroid conditions may not have lash extensions last long due to either of these* This field is required.
Yes
No
33
Blepharoplasty or other eye condition or surgery in the last 6 months? Blepharoplasty, eye surgery or conditions may have sensitivity to eye-lash extensions and products used. Consult your doctor first and ask if it's safe for you to have this service* This field is required.
Yes
No
34
I acknowledge and understand that the studio doesn’t offer refunds. LASH ALE will do their ultimate BEST to provide a service experience to meet your satisfaction. I understand that while every attempt will be made to provide me with the length and fullness I have chosen, my final result may not be what I initially envisioned.* This field is required.
I Agree
35
I acknowledge Lash ALE does their full effort to fulfill my appointments times and I respectfully acknowledge the times I schedule to be available. I understand the following set of CANCELLATION policies that are also non-refundable agreements of service. All appointments require a valid credit card. If you cancel or reschedule 18 - 12 hrs before your appointment, a $50 fee will be charged upon cancellation. No show/no call will result in a full charge. While we understand things may happen, we advise appropriate booking.* This field is required.
I Agree
36
Eyelash extensions require on-going maintenance (similar to a nail service). Refills are recommended approximately every 2 to 3 weeks. I understand if I go beyond this recommended time it may result to an incur (higher) service cost as a full-set.* This field is required.
Yes
37
It is also recommended to avoid all oil-based products around your eyes for as long as you wear your lashes. Oil based products, waterproof mascaras and liners will loosen the adhesive and your lashes will not last long. Please come to your appointments with no eye-makeup.* This field is required.
Yes
38
I release LASH ALE from any liability associated with this procedure. This service will be performed with the utmost attention to safety, sanitation, and proper application using tools and products that the technician has been trained and certified to use. This service has many variables due to lifestyle, moisture, weather, extreme temperatures, natural eyelash shedding, and other factors. The technician (along with my consent form and consultation) will decide if I am a good candidate for this service to the best of their ability.* This field is required.
Initial
39
I agree and understand that Lash Ale & my Lash Technician have no way of knowing if the client is allergic to some of the products or materials being used in any eye-lash procedure, though we do use sensitive eye products to ensure comfort every client is different. LASH ALE does offer patch tests to those that are not sure if they are a good candidate and will help to discuss options. I will seek medical care (at my own expense) and contact my technician immediately if any allergic or adverse reaction occurs. All of my questions were answered and I understand the procedure and risks.* This field is required.
Initial
40
Please agree to the terms and conditions* This field is required.
I certify that I have read all the information above.
I understand it is my responsibility to keep my eyes closed and stay still during the entire application process.
I understand that the fumes from the adhesive may cause my eyes to water during the application process
I understand that some of the risks involved with this procedure may be, but are not limited to eye redness, swelling, and/or irritation.
I hereby agree to have eyelash extensions applied to my natural lashes and consent to the placement and/or removal of the eyelash extensions by the certified professional.
I understand and agree to the after-care instructions and for any unexpected circumstance that have happened due to not following these instructions are in my own risk.
I understand that in rare occasions there are risks associated with having artificial eyelashes. I further understand that in rare circumstances eye or skin irritation and discomfort may occur.
I understand that because of the natural lash cycle and wear and tear, I will need to maintain my extensions with touch up appointments usually recommended about every 2 to 3 weeks to keep them full.
I understand and acknowledge that this consent & release discharges me, (your name here), from any liability or claim that I may have with respect to any bodily injury, personal injury, property damage, or any other claim that may result from the services provided.
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With my signature below, I attest that I have completed the above information accurately and to the best of my knowledge. I agree to notify my technician of any other relevant information that may affect my service, including changes to the information above. I will not hold my technician responsible for any damage or loss that may occur as a result of not representing my medical history accurately.* This field is required.
I Agree
42
Client Signature* This field is required.
First Name
Last Name
43
Client Hand Signature
44
Date* This field is required.
Date
Month
Day
Year
Should be Empty: