winksbyiicyg Consent Form
Clients Name:
First Name
Last Name
Instagram handle
*
example: @winksbyiicyg
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about winksbyiicyg?
instagram
family member
Friend
Other
Have you ever had lash extensions before?
Yes
No
Please agree to the terms and conditions
*
I hereby agree to have lash extensions applied to my natural lashes and consent to the placement and/or removal of the eyelash extensions by the certified professional (Genissis A.)
I understand and agree to the aftercare instructions and for any unexpected circumstances 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 that understand that in rare circumstances eye reactions or skin irritation and discomfort may occur.
I understand that because of the natural lash cycle and wear & tear, I will need to maintain my extensions with touch up appointments usually recommended about every 2-3 weeks to keep them full.
I am informing the certified lash extension specialist of the following conditions by marking the circles apply to me.
Allergy to adhesive band aid or medical tape
History of allergic reactions to lash extensions
Currently using contact lenses and must be responsible for taking them out before application.
Other medical conditions which would prohibit or compromise placement and retention of the lashes.
None apply to me
I have read the above information. If I have concerns, I will address them with my Lash Technician, Genissis A. I give permission to my technician to perform the lash extension procedure we have discussed, and will hold her harmless from any liability that may result from this treatment. I have accurately answered the questions above, including all known allergies, prescription drugs, or products I am currently ingesting or using topically. I understand that my lash technician will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult the lash tech immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the lash tech responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed at the appointment.
*
Agree
Client Name (Signature)
*
Date
/
Month
/
Day
Year
Date
winksbyiicyg - Genissis A.
Submit
Submit
Should be Empty: