Intake & Consent Form

Intake & Consent Form
Name*
IG Username*
Date*

MonthDayYear
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.*
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.*
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.*
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).*
Select any of the following that might apply to you:

Lasik Eye SurgeryIron DeficiencyHormonal Imbalance/Extreme StressPermanent Eye MakeupRecent high fever or severe illnessAllergic to GlycerinBlepharoplasty (eye lift)Allergies to adhesives or syntheticsChild birth within last 120 daysMicrodermabrasionAlopeciaThyroid diseasesHypersensitivity to cyanoacrylate or formaldehyde or certain adhesives/gluesExposure to certain chemicals found in swimming pools, and to bleach, dye, and perm hairChemotherapeutic agents used in cancer treatmentRetinoids used to treat acne and skin problems (such as Accutane or Retin A)Major surgery within last 120 daysEating disordersDrugs that can cause temporary hair lossAnticoagulantsBeta-adrenergic blockers used to control blood pressureOral contraceptives
Client Intake

select or write in
Is this the first time you’re getting lash extensions?*

YesNo
If no, where have you had them applied?*
Have you worn any of the following lashes in the last 60 days?*

StripFlareIndividualOther
Do you:*

CurlPermTintOther
Do you wear:*

GlassesContactsNeither
Do you rub, pull, or pick your lashes for any reason?*

YesNo
Do you have, or are you being treated for any eye illness/injury?*

YesNo
If yes, what?*
Which side do you predominately sleep on?*

LeftRightOther
Any eye drops/medications?*

YesNo
If yes, list them:*
Do you prefer your lashes:*

NaturalDramaticOther
How did you hear about us?
Select or write in:*

InstagramLapine Lashes WebsiteGoogle/SearchTikTokFriend (Referral)/Other
Email*

Confirmation Emailexample@example.com
Phone Number*
Format: (000) 000-0000.
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 NameLast Name
Date*

MonthDayYear
Date
Signature*
Should be Empty:

Intake & Consent Form

Waiver of Liability

Permission To Use Pictures

Care & Maintenance

Client Intake

How did you hear about us?

Failure to do so will result in not being able to book future appointments.

Signature