Lash and Brow Free Model Consent Form

1
Full Name* This field is required.
First Name
Last Name
2
Your Suburb and Post Code* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Phone Number
Please enter a valid phone number.
4
E-mail* This field is required.
example@example.com
5
Is this the first time you have had eyelash extensions applied?* This field is required.
YESNO
6
If this is not your first time getting lash extensions, where and when have you had them applied?
Please type salon name and your last appointment date with them
7
Have you had any previous issues / allergy with eyelash extensions in the past?* This field is required.
YESNO
8
What is your previous issues / allergy with eyelash extensions in the past?* This field is required.
Please be as clear as possible
9
I understand that I had issues in the past with eyelash extensions (including allergic reaction) and will proceed with the appointment today using Sensitive glue - knowing the full risk of potential irritation that may arise from lash application. This has been communicated to me by my lash technician. I am fully responsible for my own action and will not hold Mollylash and its representative legally accountable.
YESNO
10
Permission to use pictures* This field is required.I understand and consent that photographs and/or videos may be taken of me during or after my appointment for the following purposes: • Educational use in student training and assessment • Marketing and promotional use on MOLLYLASH’s website, social media platforms, or printed materials
YESNO
11
Waiver of liability* This field is required.By signing this form, you acknowledge and agree to the following: 1. Risk Acknowledgement I understand and accept that by receiving lash or brow services from a student trainee, I may be exposed to certain risks, including but not limited to: -Chemical burns -Skin burns -Conjunctivitis -Lash stickies -Uneven or inconsistent application -Poor lash retention I accept full responsibility for any reaction or result that may occur. 2. Supervision I understand that the trainee technician will be periodically supervised by a qualified master technician. Supervision will not be continuous throughout the appointment - it will be done periodically, but the final result will be inspected and approved by the supervising technician before I leave. 3. Appointment Duration I understand that appointments may take up to 3 hours due to the nature of training. I agree to remain patient and cooperative throughout the process. 4. No Compensation or Fixes I understand that this is a free training service, and as such: I am not entitled to compensation, refunds, or exchanges. I cannot request complimentary fixes, adjustments, or removal of the extensions. 5. Voluntary Participation I confirm that I am participating voluntarily and that I have no medical or health conditions that would contraindicate lash or brow treatments. I release MOLLYLASH and all its staff from any liability arising from the service received during this session.
YESNO
12
No Known Medical Conditions / Informed Consent* This field is required.I have read and completed the Free Model Consent Form in its entirety and in truth. I understand that I need to disclose any allergies that I may have to synthetics, cyanoacrylate or formaldehyde which in small amounts may be present in the adhesive. I understand that the procedure requires that I lay still with my eyes closed. 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 instructions or these warnings. This Agreement will remain in effect for this procedure, and all future procedures.
YESNO
13
Signature* This field is required.I agree that this Agreement is binding upon me, and my heirs, legal representatives and assigns. I represent that I am at least 18 years of age and that I have the right to enter this agreement.
I am over 18 years old
I am under 18 years old
14
Signature of legal guardian* This field is required.I agree that this Agreement is binding upon me, and my heirs, legal representatives and assigns. I am under 18 years of age and I have my parent or legal guardians consent to this agreement.
Clear
15
Signature* This field is required.I agree that this Agreement is binding upon me, and my heirs, legal representatives and assigns. I represent that I am at least 18 years of age and that I have the right to enter this agreement
Clear
16
You have to agree to our terms and conditions before services can be provided to you
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