New Client Consent Form

New Client Consent Form

Eyelash Extensions
Name*

First NameLast Name
Date of birth:*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
How did you hear about us?*

InstagramFacebookTikTokReferral/ Business CardOther
If you heard about us through a referral, could you please share the name of the person who referred you? I'd love to offer you both a special discount!
Please submit a passport-style photo taken in quality lighting, with your face clearly visible. This helps me determine the map that best complements your facial features.*

Cancelof
Is this your first time having eyelash extensions applied?*

YesNo
If this isn't your first time getting eyelash extensions, please share any relevant details that will help us tailor your service. Have you experienced any of the following when having eyelash extensions:

DiscomfortItching or burning sensationPulling or pinching sensationSwellingSkin irritationOther
Are you wanting eyelash extensions for a special occasion or everyday wear?*

Special occasionEveryday wear
Do you wear glasses?*

YesNo
Do you wear contact lenses? If yes, please be sure not to wear them for your appointment.*

YesNo
Have you gotten a lash lift in the last 30 day?*

YesNo
How often do you wear strip lashes or clusters?*

NeverDailyOccasionally (2x a week)Frequently (3-5x a week)
Have you used a lash growth serum in the last 6 months?*

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

YesNo
Do you have any known allergies or sensitivities? This should include allergies to adhesives, solvents, metals, acrylic, or latex.*
I am informing my technician of the following conditions by marking with a check:*

Have worn eyelash extensions (i.e., cluster lashes, strip lashes, or semi-permanent lash extensions) in the prior 10 days.Currently experience or previously experienced extreme stress/ trauma.Currently experience or previously experienced hormonal imbalances.Currently use or previously used birth control.Currently use or previously used thyroid medication.Currently pregnant or breastfeeding or experienced childbirth within the last 120 days.Currently use or previously used retinoids.Have had a blepharoplasty.Currently experience or have experienced alopecia.Currently experience or previously experienced ringworm.Currently experience or previously experienced iron deficiency.Currently experience or previously experienced seasonal allergies.Currently use or previously used Accutane.Recently experienced a high fever.Have had Lasik eye surgery or any other eye surgery.Currently experience or previously experienced dry eye.Currently experience or previously experienced blepharitis.Currently experience or previously experienced contact dermatitis.Currently use or previously used medications that can contribute to hair loss.Currently experience or previously experienced compulsive picking and pulling of hair.Have a sensitivity to cyanoacrylateOther medical conditions which would prohibit or compromise the process retention of the eyelash extensions.No conditions
What side do you primarily sleep on?*

Left sideRight sideStomachBack
Select any of the following activities in which you participate in:

Hot yogaFrequent swimmingActive lifestyleSaunaFacial/ Esthetic treatmentsHigh heat exposureCyclingOther
Do you have extremely oily skin and/ or hair?*

YesNo
What is your skincare and makeup routine?*

Skin exfoliantsSunscreenMoisturizerOil Facial CleanserSkin serumMakeup removerEye creamGel eyelinerPencil eyelinerMascaraFace powder/ eyeshadowMakeup setting spray
Check any and all of your favs....

Spa MusicMy Lash Studio PlaylistCountry MusicTrue Crime PodcastRequested MusicRequested PodcastOther
Consent
I agree to have eyelash extensions applied to my natural eyelashes.

I understand there are risks associated with eyelash extensions. I further understand that eye irritation, eye pain, eye itching, discomfort, and, in rare cases, eye infection or blurriness may occur. If I experience any of these conditions due to this service, I will notify Samantha Nicole Lashes (Samantha Aldaba) immediately and obtain medical care if necessary. I understand that I am solely responsible for any medical or otherwise costs related to treating any adverse reaction to this service.

I understand that even though my technician applies the eyelash extensions using the proper technique, the instruments, tapes, cleaners, eye gel pads, adhesives, and removers used may irritate my eyes or require a physician’s follow-up care.

I understand and agree to the care instructions provided by my technician for the use and care of my eyelash extensions. I realize and accept the consequences of failure to adhere to these instructions, which may cause the eyelash extensions not to stay attached as long as they are told.

I understand and consent to having my eyes closed and covered for the duration of the service (up to 4 hours).

I understand that eyelash extensions carry some inherent risk of irritation to the orbital eye area, including the eye itself, and could result in stinging or burning, blurry vision, and potentially blindness if the semi-permanent glue enters the eye.

I understand that if the semi-permanent glue accidentally comes into contact with the eye, eye will be flushed with water, and medical attention may be required.

I understand that the skin that comes in contact with the semi-permanent glue may experience irritation, itching, or burning.

I acknowledge that my service provider is a certified lash technician who is currently enrolled in an esthetics program, working toward licensure in the State of Oklahoma.

I understand that services are provided as part of ongoing professional development and practice. Any fee collected is for products, supplies, and materials used during the appointment, and not as a fee for licensed cosmetology or esthetic services.

I acknowledge that results are not guaranteed and that services are provided with care and proper technique based on current training.

I understand that the eyelash extensions will fall out over several weeks in accordance with my natural eyelash life cycle. Touch-ups and fills will be required to keep the eyelash extensions fresh. Most guests require a fill every 2-3 weeks.

If you are suffering poor retention, irritation, or an issue with the eyelash extension, you should contact your technician immediately to resolve the issue.

I agree to the following eyelash extensions post-application and maintenance instructions:
• No picking or pulling on your eyelashes.
• Avoid sleeping on one side of your face.
• Use a silk pillowcase to avoid pulling.
• Wash your lashes every day.
• Do not use eyelash curlers.
• Do not use mascara over the eyelash extensions.
• Avoid saunas, pool chemicals, or extreme heat for 24 hours after application.
Although every precaution will be taken to ensure your safety and well-being before and after your eyelash extension appointment, please be aware of the possible risks described above. By checking the boxes, you are agreeing to the terms and conditions listed below as well.*

I acknowledge that this release discharges Samantha Nicole Lashes (Samantha Aldaba) from any liability or claim that may result in bodily injury, illness, medical treatment, or any services provided by Samantha Nicole Lashes (Samantha Aldaba).I understand that this agreement is binding and that I have thoroughly read and comprehended all the information provided. I affirm that I am of legal age (over 18 years). If I am under the age of 18, a parent or guardian is responsible for booking the appointment.
Policy
We understand that sometimes things come up, but if you cannot make the appointment, please kindly notify us.

Weather:
As we can experience some crazy weather, please do not risk your life to make the appointment. We are happy to reschedule the appointment!

No Shows or Cancellations:
No shows or cancellations within 24 hours of the scheduled appointment will incur a 50% service charge. A 15-minute grace period is permitted beyond this time, after which the appointment will be considered a no-show, and a 50% service charge will be applied.

Payment Method:
Cash is preferred, but we also accept Apple Pay, Venmo, Cash App, and PayPal.

Refund:
Samantha Nicole Lashes does not offer refunds under any circumstances.
However, if you have issues within 48 hours of your appointment, please get in touch with us for a free correction or resolution.
I have read and accepted all of Samantha Nicole Lashes’ policies, including, but not limited to, no-shows, rescheduling, cancellation, and late fees. In the event of an emergency, I will notify my technician within 24 hours of my appointment time to avoid any fees. I concur that I have diligently reviewed and accepted all of Samantha Nicole Lashes’ policies, and I fully comprehend and accept the associated risks.*

I agree
Are you comfortable with photos being taken, recorded, and shared on social media platforms like Instagram, Facebook, etc.?*

I am comfortable being recorded for content creation, educational, and marketing purposes.I do not wish to be filmed
Should be Empty:

New Client Consent Form

Consent

Policy