Lash Extension Liability Waiver and Consent Form

1

Full Name* This field is required.

First Name

Last Name

2

Date of Birth* This field is required.If under 18 years of age, please have your parent/guardian fill this consent form out for you.

Date

3

Cell Phone Number* This field is required.

Area Code

Phone Number

4

Do you want to be contacted via text message about future appointments?* This field is required.

YESNO

5

EmailIf you want copy of form emailed to you, please enter email here.

example@example.com

7

Have you had lash extensions before?* This field is required.Answer yes if currently wearing extensions

YESNO

8

Please indicate if ANY of the following apply to you* This field is required.Scroll through entire list , “None of the Above” located at bottom.

9

List ALL Known Allergies/Relevant Medical Conditions Here:Leave Blank if None

11

Please List ANY Medications You Are Taking:Certain medications (such as thyroid medications) can affect the longevity of your extensions, and can make your natural lashes oily or brittle. Knowing medications you are taking will help prevent any retention issues and allow me to provide you with the best personalized advice.

13

Terms and Conditions* This field is required.Please read and acknowledge the following agreement, and check the "I Agree" box to continue. Date and signature required on following pages.

14

Today's Date* This field is required.

Date

15

Signature* This field is required.

Clear

16

Signature* This field is required.