Intake & Consent Form
Name
*
IG Username
*
Date
*
/
Month
/
Day
Year
Waiver of Liability
initial each box
I agree to have Lapine Lashes eyelash extensions applied to/and or removed from my eyelashes by a certified eyelash technician.
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I understand the risks of having artificial eyelash extensions applied to/and or removed from my eyelashes. Including, but not limited to: eye irritation & eye discomfort.
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I understand that even with the utmost care in the application and/or removal of these products, risks still exist associated with the procedure and product itself. Which include, without limitation: eye pain, and in rare cases eye infection or blindness when improperly handled.
*
Permission To Use Pictures
initial the box
I consent to before and after photographs being taken for the purpose of documentation, potential advertising, & promotions
Care & Maintenance
initial each box
I agree to follow the care & maintenance instructions provided on the Lapine Lashes website, and acknowledge that failure to do so may result in damage to my natural lashes and/or decrease the lifespan of my lash extensions.
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I understand that if I have a specific medical or skin condition (listed below) the application of eyelash extensions may have potential negative side effects (such as premature shedding of eyelashes).
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Select any of the following that might apply to you:
Lasik Eye Surgery
Iron Deficiency
Hormonal Imbalance/Extreme Stress
Permanent Eye Makeup
Recent high fever or severe illness
Allergic to Glycerin
Blepharoplasty (eye lift)
Allergies to adhesives or synthetics
Child birth within last 120 days
Microdermabrasion
Alopecia
Thyroid diseases
Hypersensitivity to cyanoacrylate or formaldehyde or certain adhesives/glues
Exposure to certain chemicals found in swimming pools, and to bleach, dye, and perm hair
Chemotherapeutic agents used in cancer treatment
Retinoids used to treat acne and skin problems (such as Accutane or Retin A)
Major surgery within last 120 days
Eating disorders
Drugs that can cause temporary hair loss
Anticoagulants
Beta-adrenergic blockers used to control blood pressure
Oral contraceptives
Client Intake
select or write in
Is this the first time you’re getting lash extensions?
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Yes
No
If no, where have you had them applied?
*
Have you worn any of the following lashes in the last 60 days?
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Strip
Flare
Individual
Other
Do you:
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Curl
Perm
Tint
Other
Do you wear:
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Glasses
Contacts
Neither
Do you rub, pull, or pick your lashes for any reason?
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Yes
No
Do you have, or are you being treated for any eye illness/injury?
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Yes
No
If yes, what?
*
Which side do you predominately sleep on?
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Left
Right
Other
Any eye drops/medications?
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Yes
No
If yes, list them:
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Do you prefer your lashes:
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Natural
Dramatic
Other
How did you hear about us?
Select or write in:
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Instagram
Lapine Lashes Website
Google/Search
TikTok
Friend (Referral)/Other
Email
*
Confirmation Email
example@example.com
Phone Number
*
Zip Code
*
I understand and consent to having my eyes closed throughout the procedure.
*
I understand and will follow the policies listed on the Lapine Lashes website.
*
Failure to do so will result in not being able to book future appointments.
Signature
By signing this form, I am acknowledging and understand all information listed. This agreement will remain in effect for thisprocedure, as well as all future follow-ups conducted by the technician. I consent to this agreement, and the eyelash extensionapplication/removal procedure.
*
I accept the terms listed above.
Print Name
*
First Name
Last Name
Date
*
/
Month
/
Day
Year
Date
Signature
*
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