Eyelash Extensions || Consent and Liability Waiver (v20.07)
(version20.07.25)
Client's Name
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First Name
Last Name
Date of Birth
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Day
Year
Date
Address
Street Address
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Phone Number
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Format: (000) 000-0000.
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Questionnaire
Are you allergic to any adhesives (glue, tape, band aids)? This service uses tape, glue and gel pads that can cause an allergic reaction.
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Yes
No
Do you have any other allergies, including vitamin C or fruit extracts? Please write no if you don't have any allergies, or explain in the box below). These ingredients may be used in the gel pads or other products.
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Have you had chemotherapy treatment in the last 6 months? The medication for chemotherapy can make skin extra sensitive to reactions with the ingredients used in the lash application process. Also, natural lashes may be weak after growing back from therapy.
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Yes
No
Do you have any known eye conditions, such as dryness, watering, fungal or yeast infections? Surgeries, medical treatments and medical conditions may be contraindicated for lash extensions. Please consult your health care provider before proceeding with the extension application if you answer yes to any of these options.
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Yes
No
Have you used any eyelash serums, conditioners or had eyelash treatments such as lifts or tints in the last 2 weeks?Serums, conditions, perms and tints can leave glycerine and oil that interact with the lash extensions’ adhesive and reduce effectiveness.
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Yes
No
Do you wear contact lenses? Contacts MUST be removed before eyelash extension applications to prevent the risk of damage to the contact or eye in the event of product accidentally entering the eye.
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Yes
No
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Disclaimer and Consent
I acknowledge and understand that eyelash extension applications and removals can lead to burning, stinging sensations, as well as eye watering, mucus membrane irritation and in some cases allergic reactions. I understand that I can book a consultation free of charge ahead of my regular appointment (as time permits) to participate in a patch test to reduce the risk of a surprise allergic reaction after the eyelash extension application.
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I agree
I understand that the eyelash extensions will be applied to the natural eyelashes as determined by the lash technician so as not to create excessive weight on the natural eyelash, thereby preserving the health, growth, and natural look of my natural eyelashes. I also understand that a certain amount of eyelash adhesive material will be used to attach the artificial lashes to my existing eyelashes. Even though the lash technician may apply or remove my lashes properly, I understand that 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.
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I agree
I understand that the procedure requires that I lie still in a reclined position for up to 3 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 the lash technician’s instructions or these warnings.
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I agree
I agree to avoid wetting the lash extensions for the first 24 hours post-application as best as possible. I understand that if I participate in any of the following or any other activities that may interfere with the lashes I may experience premature loss of the lash extensions, i.e. excessive swimming, sauna use, steam rooms, and or pulling on lashes, using oil based or waterproof cosmetics, and or using mechanical curlers or crimping lashes in any way.
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I agree
I agree that I will not attribute any liability to the company Gossamer Lashes or the lash technician as a result of this procedure or the use and care of my extensions. I also agree to defend, indemnify, and hold harmless the company, Gossamer Lashes, and the lash technician from any and all claims, actions, expenses, damages, and liabilities, including reasonable
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I agree
I agree that this consent form is binding upon me and my heirs, legal representatives, and assigns. By signing below, I confirm that I have read this consent form and understand it, and I give my consent to have eyelash extensions applied to and/or removed from my eyelashes.
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I agree
I give permission for my image and likeness to be used for promotional material for marketing and advertising purposes by the company, Gossamer Lashes and the lash technician. I also agree to provide my name, phone number, email and/or other necessary personal information for the purpose of appointment reminders or other appointment-related services.
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I agree
I give permission for my image and likeness to be used for promotional material for marketing and advertising purposes by the company, Gossamer Lashes and the lash technician. I also agree to provide my name, phone number, email, payment information and/or other necessary personal information for the purpose of appointment reminders or other appointment-related services.
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I agree
I confirm that I have been given an opportunity to ask questions and all of my questions have been answered to my satisfaction. If I, the client, am under the age of 18 years, I confirm that I have had my parent or guardian review this form with me, and they give consent to the eyelash application by signing below.
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I agree
Client e-signature (typed)
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Date
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Parent or Guardian e-signature (typed)
Date
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