Eyelash Extension Consent Form
Thank you for choosing opulent lash kouture. We are looking forward to a long and lengthy business relationship.
Name
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about us?
Website
Magazine
Web search
Friend
Other
Health History | Please check any of the following that applies to you
Allergy to adhesives band aid or medical tape
Allergy to surgical glue or nail glue
Seasonal allergies
Allergy to glycerin
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
Other
Have you ever had eyelashes extensions before?
Yes
No
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)
Yes
No
If yes, where have you had them applied and what brand was used?
Please agree to the terms and conditions
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.
4. I understand that even with the utmost of professional care, there are built-in risks (potentially harmful or negative side effects) associated with having artificial eyelashes applied to and/or removed from my existing natural eyelashes and with any and all products used in the application and or removal. These built-in risks include but are not limited to:● allergic reaction to the glue used to attach the eyelash extensions,● eye irritation and redness,● infection,● discomfort,● loss of natural lashes,● blindness,● disturbance and or disruption of vision,● premature shedding of natural eyelashes,● eye irritation, or● eye pain
I fully understand that a reaction can occur at any time, even if I have received this SERVICE(s) on previous occasions. I further understand that if I have any concerns, I will seek medical advice prior to any SERVICE(s).
I understand there is more than one technique for applying artificial lashes to my natural eyelashes, and I will not attribute any liability to [opulent lash kouture] as a result of this SERVICE or the use and care of these lashes.
I agree that this constitutes full disclosure, and that it supersedes any pervious verbal or written disclosures. I certify that I have read and fully understand the above information and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks.
I understand and confirm that by signing this form, I hereby waive and release [Opulentlashkouture,] from any and all claims, of every kind and nature, including claims for personal injuries, death, disease, property loss, or any other losses, including but not limited to claims of negligence. I further give up my right to any claim I may have to seek damages, whether known or unknown, foreseen or unforeseen, arising from or in any way related to the services being provided to me by [Opulentlashkouture]. Such release shall extend to [Opulentlashkouture] successors, agents, officers, predecessors, parent, subsidiary, attorneys, employees, assigns, and representatives.
I agree that by selecting the "Submit" button, I am signing this Consent electronically. I agree my electronic signature is the legal equivalent of my manual/handwritten signature on this Consent.
Date
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Month
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Day
Year
Date
Client Signature
Technician Name
First Name
Last Name
Technician Signature
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