Eyelash Extension Consent Form

1
Eyelash Extensions Consent Form

All information is held in the strictest confidence. At no given point is information disclosed or shared without the client's written consent.

I have agreed to have eyelash extensions applied and/or removed from my eyelashes. Before my qualified professional eyelash technician can perform this procedure, I understand I must complete this agreement and provide my consent by signing and dating this consent form.
2
Name* This field is required.
First Name
Last Name
3
Address* This field is required.
Street Address Line 1
City
Postcode
4
Telephone* This field is required.
phone number
Mobile
Home
Work
select type from the dropdown list
5
E-mail
6
COVID-19 Screening * This field is required.I understand that the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus has a long incubation period during which the carriers of the virus may not show not show the symptoms and may still be contagious. I understand that physical distancing of 6 feet may not be possible while in the salon receiving services. I understand that I must sanitize my hands before entering the salon and I must wear a mask that covers my mouth and nose while in common areas. Hard surfaces such as door handles, Ipads, payment terminals, and countertops will be wiped after each client. I confirm that I am not currently positive for novel coronavirus. I confirm that I am not waiting for the results of a laboratory test for the novel coronavirus. I verify that I have not returned to NH or MA from any country outside of the US, whether by car, air, bus or train in the past 14 days. I verify that I have not been identified as a contact of someone who has test positive for the novel coronavirus or been asked to self-isolate by The NH Department of Health, or any other government agency. I confirm that I am not presenting with any of the following symptoms of COVID-19 indentified by the CDC Fever > 38C, or 100F, chills or body aches Cough Sore Throat Shortness of breath Difficulty breathing Flu-like symptoms Runny Nose Loss of smell or taste I confirm that I am not in high risk category for increased illness or death from COVID-19, including : diabetes, cardiovascular disease, hypertension, lung disease including moderate to severe asthma, being immunocompromised (including transplant recipient), having active malignancy or over the age of 65. I understand that for the safety of everyone, my temperature may be checked before the services are started. I understand that I may be unable to proceed with services at The Art of Lashes if they are deemed unsafe to myself or a staff member I understand I may NOT bring children or anyone else who does not have an appointment into the salon. I understand the staff of The Art of Lashes will do everything possible to minimize the spread of COVID – 19, but will not hold them responsible should I contract the COVID – 19. I will immediately notify the salon if I contract the virus within two weeks following my visit. I verify that the information I have provided on this form is truthful and accurate.
Yes, I may have been exposed to corona virus
No, I have not been exposed and expierienced no symptoms
7
Medical Details* This field is required.Please select all that apply
Allergy to Latex, Band aids, acrylic nails, collagen, or tapes
Asthma
Hayfever
Claustrophobia
Light Sensitive
Smoker
Eye Disorders
Contact Lens wearer (must be removed for treatment)
Taking HRT or steroids, thyroid medication
Pregnant
Oily skin & hair
Chemotherapy within the last 6 months
Have you worn lash extensions before?
Blepharoplasty (must wait 6 months post-op for medical consent)
Lasik surgery (must wait 4 weeks post-op for medical consent)
None of the above
8
Additional Medical NotesPlease explain details for anything selected in the previous questionnaire
9
I understand there is risk associated with having artificial eyelashes applied and/or removed from my natural lashes. I understand that the eyelash extensions will be applied to the natural lash as determined by the technician so as not to create excessive weight on the natural eyelash thereby preserving the health, growth, and natural look of my natural eyelashes. I understand as part of the procedure eye irritation, eye pain, eye itching, discomfort and in rare cases eye infection may occur. I understand and agree that if I expierience any of these issues with my lashes that I will contact my technician and have eyelashes removed immediately and consult a physician at my own expense.* This field is required.
Yes I agree
10
I understand that even though the technician may apply and remove the extensions properly, that the adhesive materials may become disloged during and after the procedure, which may irritate my eyes or require further follow up care. I understand and agree to follow the after care instructions provided by my technician. Failure to follow the after care can cause eyelash extensions to fall out. I understand that in order to have eyelash extensions applied to my eyelashes I will need to keep my eyes closed for duration of 60-180 minutes during the procedure. I also understand that I will need to be laying in a reclined position. Any medical conditions that may be aggravated by laying still for a prolonged period may mean I will not be able to have the procedure performed on my eyes. No refunds for services performed.* This field is required.
Yes I agree
11
I understand the booking policy and agree to provide my credit card on file for no-show purposes. Cancellation/ reschedule within 24 hours of the appointment a 50% service charge will apply. No shows and any cancellation within 3 hours prior to the appointment- 100% service cost will apply. No exceptions.* This field is required.
Yes I agree
12
Privacy and Data Protection

Any data collected by The Art of Lashes will be to ensure we can safely perform your treatment and to be able to contact you with regards to appointments. We need to store this data to comply with liability insurance and to be able to safely continue treatments and keep records of all products used should any issues/allergies/problems arise.

We will store your data either in a locked cabinet that only staff have access to or (in the case of electronic formats) in secure encrypted locations accessible only through passwords or fingerprint id. We will not share your data with any third parties.

We will store this data for a period of 7 years beyond your last appointment with us to comply with our insurance company but it will be reviewed on a yearly basis where you can opt out. If you choose to opt out we will need to keep your existing data on file for insurance purposes. You can opt out at any time by contacting us in writing to The Art of Lashes LLC at theartoflashesllc@gmail.com If you decide to opt out and withdraw consent, We will no longer be able to perform any treatments on you.
13
Photographs* This field is required.Please select one of the following boxes to confirm whether you give consent to have pictures taken of your lashes and for the pictures to be used on The Art of Lashes website and social media platforms (Facebook, Instagram). Photographs will be posted anonymously with identifying features cropped.
Agree
Disagree
14
Date* This field is required.Please select today's date from the calendar
Date
Month
Day
Year
15
I Certify that I am at least 18 years of age, and If not, I understand that my parent or legal guardian must be present during appointment check-in and must sign this consent form on my behalf.
I am older than 18 yrs
I am younger than 18 and have my parent or legal guardian present
16
Client Signature* This field is required.By my electronic signature below, I agree to the lash treatment policy and client agreement.
17
Tags
[object Object]
Should be Empty: