CLIENT WAIVER FORM EYELASH EXTENSIONS
CLIENT NAME
*
First Name
Last Name
CLIENT ADDRESS
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PHONE NUMBER:
Format: (000) 000-0000.
EMAIL:
*
example@example.com
HAVE YOU EVER HAD EYELASH EXTENSIONS BEFORE?
YES, FOR SPECIAL OCASION
YES, FOR DAILY WEAR
NO
PRIOR REACTIONS TO LASH EXTENSIONS?
*
YES
NO
IF YES ,EXPLAIN:
HEALTH HISTORY - PLEASE CHECK ANY THAT APPLY TO YOU:
ALLERGIC TO ADHESIVE, GEL PADS, MEDICAL TAPE, LATEX, ADHESIVE BAND AID
ALLERGIES (PLEASE SPECIFY):
EXPERIENCING HAIR LOSS
ALOPECIA
SKIN CONDITIONS (ECZEMA, ETC.)
CHEMOTHERAPY
USE OF CONTACT LENSES/GLASSES
EYE CONDITIONS (BLEPHARITIS, STYES, CONJUNCTIVITIS, DRY EYES, ETC.)
CURRENT MEDICATIONS OR TOPICAL TREATMENT NEAR THE EYES
CURRENT USE OF LASH SERUMS
PREGNANT
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Eyelash Extension Risks and Considerations:
1. I acknowledge that eyelash extension services carry inherent risks, including the possibility of eye irritation or allergic reactions to the adhesive, gel pads, or other products used during the service.
2. I understand that there may be a risk of discomfort, temporary redness, or minor swelling following the eyelash extension application.
3. I acknowledge that eyelash extensions may not be suitable for everyone, and I have disclosed any eye conditions, infections, or sensitivities that may impact the application of lash extensions.
Changes in Lash Thickness and Length:
1. I understand that the result of the eyelash extension service may vary depending on my natural lash health, lash cycle, and the lash technician's expertise.
2. I acknowledge that the synthetic lashes used for eyelash extensions may be around 30-50% thicker and 20-50% longer than my natural lashes.
3. I understand that the lash technician will consider my natural lashes' health and recommend a suitable lash thickness and length for a natural and comfortable appearance.
Eyelash Extension Aftercare:
1. I have been provided with aftercare instructions for my lash extensions, and I understand the importance of following these instructions to ensure the longevity and appearance of the lashes.
2. I understand that regular lash maintenance appointments may be required to keep my lash extensions looking their best.
Possible Risks and Adverse Reactions:
1. I acknowledge that while rare, allergic reactions to lash extension adhesives can occur.
Symptoms may include redness, itching, swelling, or irritation in the eye area.
2. I understand that if I experience any adverse reactions, I must contact ADDYSON PANGAN immediately and seek medical attention if necessary.
Consent and Agreement:
By signing below, I acknowledge that I have read and understood the information provided in this consent form. I consent to receive the eyelash extension services as described, and I agree to follow the aftercare instructions provided by the lash technician.
I release
ADDYSON PANGAN
and
DEW AESTHETICS
from any liability related to the eyelash extension service or any adverse reactions that may occur.
CLIENTS NAME (PRINT)
*
First Name
Last Name
CLIENTS SIGNATURE
*
PARENT/GUARDIAN NAME (IF UNDER 18)
First Name
Last Name
PARENT/GUARDIAN SIGNATURE (IF UNDER 18)
DATE
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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I AUTHORIZED THE FOLLOWING (OPTIONAL):
BEFORE AND AFTER PHOTOS/VIDEOS BE TAKEN
MY PICTURES/VIDEOS MAY BE USED FOR EDUCATIONAL OR MARKETING PURPOSES.
CLIENT NAME/ (PRINT)
First Name
Last Name
CLIENT SIGNATURE
PARENT/GUARDIAN NAME (IF UNDER 18)
First Name
Last Name
PARENT/GUARDIAN SIGNATURE (IF UNDER 18)
DATE
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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