Keha Couture Beauty Eyelash Extension Consent and Waiver of Liability

Eyelash Extension Consent & Waiver of LiabilityHi there, please fill out and submit this form before your appointment. If you have any questions or concerns regarding the form please contact us at 469.796.9952. We look forward to seeing you!

Keha Couture Beauty takes every precaution to ensure your safety and well-being before, during, and after your lash extension application, please be aware of the following information and possible risks.

Name* This field is required.Please fill in First and Last Name ( No Nicknames)

First Name

Last Name

Date of Birth* This field is required.Please fill in your date of birth

Date

Email* This field is required.Please type in email address

example@example.com

Phone Number* This field is required.Please enter 10 digit mobile number

Have you ever had eyelash extensions before?* This field is required.

If yes, what type and was there any discomfort during or after the procedure? * This field is required.

If no, we recommend a patch test. Please initial if you are opting out of the advised adhesive patch test. * This field is required.

Please initial that you understand that a patch test does not guarantee that a adverse reaction will not happen.* This field is required.

Have you had any allergies or an allergic reaction?* This field is required.

If yes, please clarify...* This field is required.

Do you have or had any of the following ?* This field is required.

Allergic to Adhesives (glues, tapes, band aids, etc.)

Chemotherapy Treatments within the last 6 months?

Thyroid/ Hormones Medications

Lasik Surgery less than 4 months (must wait 4 weeks post-op exam for medical consent)

Blepharoplasty (must wait 6 months post-op for medical consent)

Contact Lenses

None of the above

Please add anything else you may seem appropriate that could effect having eyelash extensions.* This field is required.

Please read each statement and acknowledge by checking each box:* This field is required.

I 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 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.

I understand that additional conditions could occur or be discovered during the procedure which could affect my ability to tolerate the procedure.

I 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 at Keha Couture Beauty.

I understand and agree to the aftercare 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 understand that lash extension services have some inherent risk of irritation to the orbital eye area, including the eye itself, and could result in stinging and burning, blurry vision and potential blindness should the adhesive enter the eye or should an allergic reaction occur.

I understand that this is a semi-permanent procedure, as my natural lashes will continue to grow and fall out normally, making infill appointments necessary to maintain the original look achieved by replacing the lashes that have fallen out. Most clients require an infill appointment every 2-3 weeks with having 40% of eyelash extensions still attached.

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.

I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications.

I consent to “before and after” photographs for the purpose of documentation, potential advertising and promotional purposes. I understand that if I have any concerns, I will address these with my lash extension specialist.

I understand that 24hrs notice is required prior to my lash for rescheduling or cancellation, failure to do so will incur a $20 fee.

Keha Couture Beauty doesn't offer refunds. If any issues do occur within 48hrs from your service, please don't hesitate to get in contact. More than happy to fix the issue.

More than 15 minutes late, appointment is automatically cancelled and will need to reschedule.

No shows will incur a $20 fee.

I understand there are risks associated with having artifical eyelashes applied to and/or removed from my existing eyelashes, and that not withstanding the utmost of care in the application or removal of these products, there still risks associated with the procedure and product itself, which include, without limiation, 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 exsiting adhesives and a reaction occurs to dissolve the adhesive that results in 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 damage to my eyes.

The 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 Keha Couture Beauty from all claims, demands, damages, actions, and causes of action arising out of their performance of the service. 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.

Please Read the following to prepare for your Lash Appointment!If you have any questions please reach out to us at 469.796.9952

Terms and Conditions* This field is required.

Signature* This field is required.

Keha Couture Beauty

2617 Ellis Ct

Plano, TX 75075

P: 469.796.9952 / kehacouturebeauty@gmail.com

www.kcb.glossgenius.com

My Products

My Bag

Product Name
Please enter a short description.
$10.00Edit
Back
1
1
2
3
4
5
6
7
8
9
10
Quantity

Payment Methods

Choose from one of the PayPal options to make your payment.