New Client Consent form
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date
/
Month
/
Day
Year
Date Picker Icon
Are you experiencing any of the following?
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Discomfort
Itching or burning sensation
Pulling or pinching sensation
Swelling
Skin irritation
N/A
Other
Removal of lash extensions applied at a foreign studio may expose visible breakage, gaps, thinning, and accumulated damage as direct result of the original application technique. Osita Lashes is not responsible for the condition of my lashes post removal.
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I understand and acknowledge this policy
Client History
All answers are confidential
Is this your first time receiving a lash service?
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Yes
No
Please provide a description of your last service. List any helpful details that will allow us to customize your experience. Examples: Desires, expectations, etc. ....
What lash service are you receiving?
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Please Select
Eyelash extentions
Lash removal
Lash lift
Please include anything relevant to your current health status within the last 6 months:
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Consent
I have been provide with access to the specified procedure guide and acknowledge the policies within. I have been made aware of the risks associated with my chosen treatment. By consenting, I am waiving any provider liability and agree to hold my provider harmless.
*
I do NOT consent
I consent
I hereby give my permission to Osita Lashes (Kelly Barranco) to use my photographs for promotional purpose on social media platforms including, but not limited to instagram, Facebook and Tik Tok.
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I do NOT consent
I consent
I agree to follow all aftercare instructions (e.g. avoid oil-based products, avoid water/steam for 24 hours, avoid rubbing, etc.), and understand that failure to do so may reduce the life of the extensions or cause complications.
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I agree
To the maximum extent permitted by law, I release and hold harmless the lash technician, studio, and its agents from any liabilities, damages, or claims arising from or related to the procedure—including those caused by undisclosed medical conditions or reactions.
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I agree
I confirm that the medical and ocular history above is true and complete to the best of my knowledge, and I will inform the technician of any changes in my health before future sessions
*
I agree
I consent to the lash extension procedure and permit the lash technician to remove or stop the procedure at any time if deemed necessary for safety.
*
I do NOT concent
I consent
Client Signature
*
Submit
Submit
Should be Empty: