Lash Extensions - Client Consent & Waiver Form

Lash Lift - Client Consent & Waiver Form
*Please be sure to complete this form, prior to your lash lift service begins. We do have paper copies available, if you are unable complete this form electronically. Thank you!
Today's Date *

Month Day Year
Date
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Email *
example@example.com
Birth Date *

Month Day Year
Date
How did you hear about us?

Goggle Twitter Facebook Instagram Yelp Friend/Family
Have you ever had a lash lift service completed on your eyelashes before? *

Yes No
When?
Where?
If Yes: did you have any adverse reactions or negative experiences during or after the procedure? If Yes: What happened?
Are you having them applie for daily wear or special occasion? d *

Daily Wear Special Occassion
Do you wear contacts? (Please understand we may ask you to remove them before the application) *

Yes No
Have you been treated for any eye illness or injury? *

Yes No
Please list any eye drops or eye medications you are using:
Additional Comments:
Please initial at each line and sign at the bottom.
I understand that there are risks associated with the Ellebana or Fall Into the Volume Lash Lift procedure. Initial: *
I understand that the lashes will be curled with an advanced solution and a conditioning cream. Initial: *
I understand that as part of the procedure eye irritation, pain, itching discomfort and in rare cases eye infection may occur. Initial: *
I understand and agree to follow the aftercare instructions provided by my technician. Initial: *
I understand failure to follow the aftercare instructions may cause an undesirable result. Initial: *
I understand that in order to have a Lash Lift procedure, I will need to keep my eyes closed for duration up to 60 minutes during the procedure. I also understand that I will need to be lying in a reclined position. Any medical conditions that might be aggravated by lying still for a prolonged period of time may mean that I will not be able to have the procedure performed on my eyes. Initial: *
I understand that opening my eyes at any point during the Lash Lift procedure is not recommended, and may cause an undesirable result. I agree to keep my eyes closed throughout the procedure unless instructed to open them by my technician. Initial: *
This agreement will remain in effect for this procedure and all future Lash Lift procedures conducted by my technician or any other technician conducting business at the salon/studio listed below. I understand that this agreement is binding and that I have read and fully understand all information above. I represent that I am over the age of 18 years. If below 18 years of age a parent or guardian must also sign this form. Initial: *
I release my technician or salon/studio Exclusive Lash Bar & Nail Candy from all liability associated with this procedure. There are no guarantees for how long the lash lift will last, on average it lasts between 6-8 weeks. Our company or salon is not responsible for any technician errors. I understand that I have been advised to follow the aftercare protocol from my technician so as to avoid any discomfort or adverse side effects after the procedure has been completed. Initial: *
RESULTS MAY VARY. Our eyelashes are each unique and require slightly different processing times based on coarseness and density. If desired results are not achieved, processing times will be adjusted for future lifts. Please understand your lash health is our utmost priority, and we take careful consideration to not over-process your lashes. *
Exclusive Lash Bar & Nail Candy may use your before & after photos on our website or social media. Please indicate if you prefer to not allow us to use photos of you or your lashes. *

Yes, you may use my photos. No, please do not use my photos.
This agreement will remain in effect for this procedure and all future follow-ups conducted by the eyelash professional. I read English and understand that this consent agreement is legal and binding. I have read and fully understand all information in this agreement. I am over 18 years of age and consent to the agreement and to the lash lift application procedure. *

I agree and I understand.
Client Signature *
Should be Empty:

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Lash Lift - Client Consent & Waiver Form

*Please be sure to complete this form, prior to your lash lift service begins. We do have paper copies available, if you are unable complete this form electronically. Thank you!