Micropigmentation Informed Consent

Name*

First NameLast Name

Date of birth:*

Date

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

How did you find us:*

Have you had eyelash extensions applied before?*

YesNo

Are you currently taking any medications?

Do you have any conditions or contraindications I should be aware of, such as an eye infection, cyanoacrylate allergy, or dry eyes,...?

Please select any that apply to your lifestyle:*

What side do you primarily sleep on?*

Left sideRight sideBackStomach/ On Face

Do you have a tendency to pick or pull your lashes?*

YesNo

if yes, please describe:

*** Waiver of Liability ***

I understand there are risks associated with having artificial 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 exist risks associated with the procedure and product itself, which include, without limitation, eye irritation, eye pain, discomfort, and, in rare cases, blindness even when applied in the usual manner.

If I experience any irritation, redness, puffiness, itchiness, an allergic reaction or any other side effect of this procedure, I will contact a medical doctor immediately.

As part of this procedure, I understand that a certain amount of eyelash adhesive material will be used to attach the artificial eyelashes to my existing eyelashes. Even though the eyelash extension artist may apply or remove my eyelash extensions in the usual manner, I understand adhesive material may become dislodged during or after the procedure, which may irritate my eyes or require further follow-up care, at my own expense to prevent damage to my eyes. I also understand there is more than one technique for applying eyelash extensions to my eyelashes, and I will not attribute any liability to the eyelash extension artist as a result of this procedure or the use and care of these lashes.

As part of the removal procedure, I understand that a certain amount of chemical adhesive remover is applied to existing adhesives and a reaction occurs to dissolve the adhesive that results in the 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.

I also agree to defend, indemnify and hold harmless the eyelash extension artist from any and all claims, actions, expenses, damages and liabilities, including reasonable attorneys’ fees which might be asserted against her as a result of my having this procedure performed, or my purchase of these eyelash extension products from her.

*** Permissions to Use Photographs ***

I hereby grant the eyelash extension artist the full right to take, publish and reproduce photographs of me, my face, my eyes and/or eyelashes, both before and after this procedure, for any advertising, education, or other purposes whatsoever, including the right to retouch these photographs as deemed necessary by the eyelash extension artist. I further expressly assign any copyright in these photographs to the eyelash extension artist. I also grant my consent for the eyelash extension artist to use my image and likeness as contained in these photographs for any advertising or other purposes.

*** Care and Maintenance ***

I agree to follow the care and maintenance instructions provided by the eyelash extension artist for the use and care of my eyelash extensions, and that if any follow up care is required due to my own mistake or negligence, or failure to follow these instructions, this will be at my own expense and risk. I understand that if I do any of the following, it may result in damage to my eyelash extensions or may cause my lashes to fall off prematurely. I understand I have 24 hours after the appointment to let us know if there is something wrong with my lashes. After that, I agree Smilelash is not liable for happens with my lashes after 24 hrs from the appointment.

*** No Known Medical Conditions / Informed Consent ***

I have read and completed the Eyelash Extension Intake Form in its entirety and in truth. I acknowledge that I have been advised of the potential harmful or negative side effects (such as the premature shedding of my eyelash) that the lash extension procedure or removal may cause to those who have specific medical or skin conditions. I understand that the adhesives and adhesive remover are a skin, eye and mucus membrane irritant and that in rare cases persons may be allergic or have hypersensitivity to synthetics, cyanoacrylate or formaldehyde, which in small amount may be present in the adhesive. I understand that the procedure requires that I lay still for up to 2 hours or longer with my eyes shut, and that if I wear contacts, I must remove my contact lenses for the duration of the lash extension application or removal. I further state that I have no known medical condition that might be aggravated by the procedure or any medical condition that would prevent me from complying with or heeding to the eyelash extension artist's instructions or these warnings.

I agree to the Waiver of Liability, Permissions to use Photographs, Care and Maintenance terms, No Known Medical Conditions/Informed Consent. *

I understand there are no refunds on services rendered; this includes allergic reactions and retention of Extensions. There is no guarantee of results on any service. Results vary from client to client.*

I consent

I acknowledge the 24 hour cancellation + rescheduling policy. My credit card is provided (v when booking appt) for my account in any event of appointment no-shows or cancellations that violate Smilelash appointment policy.*

I consent

Signature*

Name*

First NameLast Name

Date*

Date

Eyelash Extensions Consent Form

Waiver of Liability