Client Information
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
How did you hear about us?
Do you have an instagram? Let's connect!
Emergency Contact Name
*
Emergency Contact Phone Number
*
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Health Information
Have you ever had lash extensions before?
*
Yes
No
If yes, when and how frequently?
If yes, Did you have any adverse reactions? Please Explain
Do you wear
*
Glasses
Daily Disposable Contacts
Extended Wear Contacts
Permanent Contacts
None of the above
How do you Sleep? (Sleeping with any contact of your lashes to a pillow or person can result in premature lash extension loss)
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Right Side
Left Side
Back Only
Stomach
All Over the Place
How would you describe your hair growth?
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Fast
Slow
Not Sure
Are you pregnant?
*
No
Trying
1st Trimester
2nd Trimester
3rd Trimester
Do you have a tendency to rub or pull on lashes?
*
Yes
No
Activity Level
*
I do not exercise
I do exercise, details below
Other
Are you allergic to Acrylates or Cyanoacrylates? (ex: Dermabond)
*
Yes
No
Are you allergic to tape?
*
Yes
No
Are you allergic to nail Adhesive?
*
Yes
No
Are you allergic to Long-Lasting or Waterproof Cosmetics?
*
Yes
No
Are you allergic to Topical Cosmetic Ingredients?
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Yes
No
Please explain any other allergies you are aware of:
List all current medications, herbal supplements, and vitamins:
Please list all conditions that apply to you:
Acne
ALlergies
Alopecia
Anticoagulants
Asthma
Autoimmune Disease
Back Pain
Bell's Palsy
Birth Control
Blepharitis
Bronchitis (Chronic)
Cancer
Claustrophobia
Cole Sore
Conjunctivitis (Pink Eye)
Convulsions/Epilepsy
Depression
Diabetes
Diabetic Retinopathy
Diet/WeightLoss
Dry Eye Syndrome
Eye Sties or Sores
Fungus
Glaucoma
Gout
Heavy Eyelid
High Blood Pressure
High Cholesterol
Hormone Imbalance/Hormone Therapy
Inflammation
Leamy Eye of Excessive Tearing
Migraines
Ocular Rosacea
Overactive Bladder Parkinson's disease
Rosacea
Seizure Disorder
Sensitive Eyes
Sensitivity to Light
Sinus Problems
Stress
Stroke
Tendency of Redness, Rashes or Hives
Thyoid Disease
Trichotillomania (Hair or eyelash pulling)
Ulcers
Terms & Conditions
I authorize Veronica Tristan to perform eyelash extension application. I understand this procedure requires individual synthetic fibers to be adhered to my own natural lashes. I understand that it is my responsibility to be still during the application and to keep my eyes closed during the entire process until otherwise advised. I have been fully informed as to the methods and procedures concerning the semi-permanent eyelash extension application. The risks of the cosmetic procedure I have chosen have been disclosed to me. Some cases may result in complications, such as transient eye redness and irritation and allergic reaction to the medical adhesive or any other products used. If at any time I (or the Esthetician) are uncomfortable with the procedure. I will inform the Esthetician and she will gladly rectify the problem, including ending the session if I (or the Esthetician) wish. It has been represented to me that no guarantees, warranties, promises, commitments or other statements as to the results of this treatment have been made, and I acknowledge that I have received no particular representations or guarantees, and I am consenting to the procedure at my own risk. I have revealed or disclosed on the form above, all conditions and circumstances regarding my health and health history, medications being taken and any past reactions to products used or medications taken. Additional conditions could occur of be discovered during or after the procedure, which could affect my ability to tolerate the procedure.
*
I accept
I do not Accept
I understand the longevity of my eyelash extensions requires my careful maintenance. I understand that basic makeup application and normal lifestyle can resume after the application. However, I should avoid the following activities which could result in a weaker bond, premature lash extension loss and/or irritation: sleeping on the side or stomach; receiving chemical treatments; and receiving irritating eye-area treatments. I understand I need to avoid excessive swimming, sauna, steam rooms, pulling on lashes, using oil-based or waterproof cosmetics, using mechanical curlers of crimping lashes in any way. I understand that the use of non-eyelash extension products may result in premature loss of my extensions.
*
I accept
I do not accept
I release, give up, acquit and discharge Veronica Tristan and/or anyone affiliated including any partnership, corporations or company associated with said individual from any claims or damages of any nature. I agree to pay any costs of legal services necessary to further effector confirm said release. I further agree that this release shall be in contemplation fo any possible damages, either known or unknown at the signing of this waiver and please form, and said damages are specifically waived following the signing of this waiver and release form. I further agree that in the event of any litigation ensues, it shall be placed before the American Arbitration Association for resolution. I agree that in the event a decision is determined in favor of one party of the other, the prevailing party shall be entitled to reasonable attorney fees and costs as set by the arbitrator. I further agree to hold Veronica Tristan and Unique Impressions nameless and harmless from any and no all damages. I release Veronica Tristan from any responsibility for pre-existing conditions I have not revealed, or any consequential change to those conditions that arises subsequent to the procedure. I understand that I am responsible for any medical treatment I may need to receive as a result of receiving this procedure. I accept full responsibility for these and any other complications, which may arise or result during or following the eyelash extension procedure(s), which are to be performed at my request.
*
I accept
I do not accept
I certify that I have read and fully understand the above waiver and release form. I certify that I have consulted with Veronica Tristan and have had all of my questions answered. I accept the explanation of potential complications and risks described herein. I certify I am of sound mind, and I am fully capable of executing this Waiver and Release for myself. I acknowledge and fully understand that there might be other unknown risks not reasonably foreseeable at this time. I, the client herein signed, for the purposes of documentation, hereby consent to "before and after" photographs.
*
I accept
I do not accept
I opt to allow the use of my before and after photos for use on our business media (website and social media).
*
Yes
No
Rescheduling or cancellation requires a 24 hour notice to avoid a 50% service charge. If you are not here 20 minutes past your scheduled appointment time, you will be considered a no show. No shows are charged 100%.
*
I accept
I do not accept
I have filled out this form accurately and honestly. I understan all terms and conditions.
Signature
*
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