The Wink Lab - Service consent form

Name*

First NameLast Name
What service are you having today?*

Brow ServicesEyelash Extensions or Lash Lift and Tint or Lash Tint or RemovalBrow Microblading or Brow PowderClasses and CertificationsOther
Location*

Miami FLWest Chester PAPhoenixville PA
IMPORTANT

All information provided is to be kept confidential and will not be disseminated to third parties unless client consent to such:
EYELASH EXTENSIONS - BROW SERVICES AND TINTING

CONSENT
E-mail*
Phone Number:*

Area CodePhone Number
Birth Date:

MonthDayYear
Where did you hear about us?*

A Friend or colleagueGoogleYelpFacebookInstagramOther
(EYELASH SERVICES) Please list any eye drops or eye medication you are using
Please check off any of the following that might apply to you:

Lasik Eye SurgeryPermanent eye make-upBlephroplasty (eye lift)MicrodermabrasionAllergies to adhesives or syntheticsChild birth within last or next 120 daysAlopeciaThyroid diseasesAllergic to GlycerinHypersensitivity to cyanoacrylate or formaldehyde or certain adhesives/gluesRecent high fever or severe illnessIron DeficiencyHormonal imbalance or extreme stressExposure to certain chemicals found in swimming pools, and to bleach, dye and perm hairEating DisordersDrugs that can cause temporary hair lossChemotherapeutic agents used in cancer treatmentRetinoids used to treat acne and skin problems (such as Accutane or RetinA)AnticoagulantsBeta-adrenergic blockers used to control blood pressureOral contraceptivesMajor surgery within last 120 days 1
(BROW SERVICES) If Yes, please list (include any antibiotics, Retinol A, Benzoyl peroxide etc)
(BROW SERVICES) Please list any allergies you have:
(BROW SERVICES) What over-the-counter or prescription skin care products are you currently using?
(BROW SERVICES) Please list any illnesses or conditions you are being treated by a physician for and list any medications you are taking, including over-the-counter herbs, vitamins and supplements:
(BROW SERVICES) : If you had an adverse reaction to a previous tinting, please explain:
(BROW SERVICES) : List any allergies
(MICROBLADING SERVICES) Have you ever had the following:

History of MRSABotoxDiabetesHepatitisBrow LiftFace LiftEasy BleedingAlcoholismAbnormal Heart ConditionAre you pregnant?Autoinmune DisordersThyroid ConditionsOily SkinCancerAccutanetanning bootDifficulty numbing during dental wokUse of blood thinners (aspirin, ibuprofen, cumadin)Allergic reaction to LidocaineAny diseases or conditions not listed.I DO NOT HAVE ANY CONDITION
MICROBLADING SERVICES CONSENT FORM

I UNDERSTANT WHEN GETTING MICRIBLADING SERVICES THERE IS A POSSIBLE RISK, HAZARDS AND COMPLICATIONS

PAIN: There can be pain, even after the topical anethetic has been used, Topical anesthesics work better on some people than others.

INFECTION: Infection is very unusual. See aftercare guidelines.

UNEVEN PIGMENTATION: Pigment may appear uneven due to bleeding during procedure, poor healing or aftercare. These isuues will be addressed at you follow up appointment.

ASYMMETRY: Every effort will be made to avoid asymetry, Faces are not symmetrycalto begin with, any realistic adjustments can be made on the folow up session.

SWELLING, REDNESS OR BRUISING: Bruising is almost never seen. Some people swell, while others do not. Swelling shpuld disappear in a few hours.

BLEEDING: Bleeding during microblading should be a "pin point" if you bleed mor than "pin point" you may not have desirable results.

ANESTHETICS: If you are not allergic to any numbing agents you must inform us inmediately.

YOU ARE AWARE THAT THE ALTERNATIVE TO THESE POSSIBILITIES IS TO WEAR TRADITIONAL MAKE UP ON YOUR FACE / EYEBROWS AND NOT UNDERGO THIS PROCEDURE.
EYELASH OR BROW SERVICES PROCEDURE CONSENT

I have agreed to have eyelash extensions or Brow services applied to and/or removed from my eyelashes or facial hair. Before my qualified professional can perform this procedure, I understand I must complete this agreement and provide my informed consent by signing and dating where indicated below.

For valuable consideration, in order to have my eyelash extensions applied and/or removed from my eyelashes:

1. Waiver of Liability. I understand there are risks associated with having artificial eyelashes applied to and/or removed from my existing eyelashes, and that not with standing the utmost of care in the application or removal of these products, there still exist risks associated with the procedure and product itself, which include, without limitation, eye irritation, eye pain, discomfort, and, in rare cases, blindness. As part of this procedure, I understand that a certain amount of eyelash adhesive material will be used to attach the artificial to my existing eyelashes. Even though the Professional may apply or remove my lashes properly, I understand 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. I also understand there is more than one technique for applying to my eyelashes, and I will not attribute any liability to Professional or The Wink Lab LLC as a result of this procedure or the use and care of these lashes. I also agree to, indemnify and hold the Professional not liable any and all claims, actions, expenses, damages and liabilities, including reasonable attorneys’ fees which might be asserted against them as a result of my having this procedure performed. As used in this agreement, the terms “Professional” and include all of their respective officers, directors, agents, employees, successors and assigns.

2. Permission to Use Pictures. I hereby grant to Professional and Alejandra Arango Uribe, Lash the full right to take, publish and reproduce photographs of me, my face, my eyes and/or eyelashes, both before and after this procedure, for any advertising, education, or other purposes whatsoever, including the right to retouch these photographs as deemed necessary by Alejandra Arango Uribe. I further expressly assign any copyright in these photographs to Alejandra Arango. I also grant my consent for Professional to use my image and likeness as contained in these photographs for any advertising or other purposes, along with any comments I may provide.

3. Care and Maintenance. I agree to follow the care and maintenance instructions provided by Alejandra Arango Uribe and/or Professional for the use and care of my , and that if any follow up care is required due to my own mistake or negligence, or failure to follow these instructions, this will be at my own expense and risk. I understand that if I do any of the following, it may result in damage to my or may cause my lashes to fall off prematurely. Knowing this I agree to follow these tips for best results: I will avoid oil based eye products as these will loosen the bond of my extensions. I will avoid getting my lashes wet within the first 48 hours after my application. For the first two days after application I understand it is best to avoid swimming, saunas or steam rooms. If I experience any itching or irritation, I agree to contact Alejandra Arango Uribe or Professional immediately to have the lash extensions removed. I agree to avoid using waterproof mascara and to not use an eyelash curler, perm, or tint my lashes. I agree to not pick, pull or rub my extensions. I understand that I should not attempt to remove my lash extensions on my own or with any product, but that the procedure requires that my lash extensions be professionally removed. If after following instructions given by Professional and/or The Wink Lab LLC my lashes are detached or all out will not hold Professional and/or The Wink Lab LLC liable for the detachment and Professional and/or The Wink Lab LLC are not required to conduct a refill free of charge.

4. No Known Medical Conditions / Informed Consent. I have read and completed the The Wink Lab Client Intake Form in its entirety and in truth. I acknowledge that I have been advised of the potential harmful or negative side effects (such as the premature shedding of my eyelash) that the lash extension procedure or removal may cause to those who have specific medical or skin conditions. I understand that the adhesives and adhesive remover are a skin, eye and mucus membrane irritant and that in rare cases persons may be allergic or have hypersensitivity to synthetics, cyanoacrylate or formaldehyde which in small amount may be present in the adhesive. I understand that the procedure requires that I lay still for up to 2 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 to the professional’s or instructions or these warnings.

If The Wink Lab LLC action is brought to enforce the terms of this Agreement, the The Wink Lab LLC shall be entitled to its costs and reasonable attorneys’ fees. Any claims arising out of this agreement will be resolved through binding arbitration in the State of PA using the rules of the American Arbitration Association.

This agreement will remain in effect for this procedure, and all future procedures conducted by Professional or any other professional conducting business at the salon/spa establishment listed above.

COVID 19 WAIVER:

I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.
I further acknowledge that Aesthetic Design By Jo has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.
I further acknowledge that Aesthetic Design By Jo can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, salon staff, and other salon clients and their families.
I voluntarily seek services provided by THE WINK LAB LLC and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment.
I attest that:
* I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.
* I have not traveled internationally within the last 14 days.
* I have not traveled to a highly impacted area within the UK in the last 14 days.
* I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.
* I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non contagious by state or local public health authorities.
* I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.
I hereby release and agree to hold THE WINK LAB LLC harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the salon, or that may otherwise arise in any way in connection with any services received from THE WINK LAB LLC. I understand that this release discharges THE WINK LAB LLC any liability or claim that I, my heirs, or any personal representatives may have against the salon with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from THE WINK LAB LLC. This liability waiver and release extends to the salon together with all owners, partners, and employees.

Although every precaution will be made to ensure your safety and well-being before, during and after your tinting application, please be aware of the possible risks below.

I understand that tinting lashes or brows has some inherent risk of irritation to the orbital eye area, including the eye itself, and could result in stinging or burning, blurry vision and potentially blindness should the tint enter into the eye.

I understand that if the tinting agent, developer, or mixture of both accidentally comes into contact with my eye, my
eye will be flushed with water and medical attention may be required.

I understand that some irritation, itching or burning may occur to the skin which comes in contact with
the tinting agent.

I understand that there may be some residual dark staining left on the skin following the tinting process of
either my lashes, brows or both. This will fade and go away within a short time.

I understand that, while every attempt will be made to provide me with my chosen color, everyone’s hair absorbs
color differently and my final results may not be the color I initially wanted.

I understand that over the course of several weeks, the tint will gradually lighten and fade. Re-tinting will be required
to keep the new color fresh. Most clients need to re-tint every 3-4 weeks.
I agree that this Agreement is binding upon me, legal representatives and assignees. I represent that I am over 18 years of age and that I have the right to enter this agreement, or if I am under 18 years of age, I have had my parent or legal guardian consent to this agreement, and his or her relationship to me is as follows:

By his or her signature below, he or she ratifies and consents to this procedure under these terms.
Date

YearMonthDay
Date
Customer Signature: *

Clear
Full Name
Parent/Guardian Signature:

Clear
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CLASS CANCELLATION POLICY

As we reserve a full day to provide you with our training services, we do not offer refunds for any of our training sessions. However, we do allow for the transfer of the reservation to another student or a future date.

Please note that you have up to six months to complete your certification.

It is your responsibility to schedule Class 2 and 3 to ensure you get your certification.
Which class are you attending?
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IMPORTANT

EYELASH EXTENSIONS - BROW SERVICES AND TINTING