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Eyelash Extension Procedure Agreement and Consent Form
Eyelash Extension Agreement and Consent Form
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How did you hear about Us?
Google/ Web Search
If referral, whom?
Is this the first time you've had lash extensions applied?
If no, did you have any reaction?
If Yes, please describe
Do you do any of the following to your lashes?
None of the above
Are you having lash extensions applied for:
A special occasion
Do you wear contacts?
Do you habitually rub, pull or pick your lashes for any reason?
Do you have, or are you currently being treated for any eye illness or injury?
What side do you predominantly sleep on?
Please list any eye medications you are using:
Are you able to keep your eyes closed and lie still for up to 2 hours or longer?
please select all that apply
Hypersensitivity to cyanoacrylate or certain adhesives/glues
Recent high fever or severe illness
Hormonal imbalance or extreme stress
Frequent exposure to certain chemicals found in swimming pools, bleach, dye or permed hair.
Major surgery within the last 120 days
Drugs that can cause temporary hair loss
Chemotherapeutic or radiation agents used in cancer treatments
Retinoids used to treat acne and skin problems (such as Accutane or Retin A)
Beta-adrenergic blockers used to control blood pressure
New oral contraceptives
Lasik Eye surgery
Permanent eye make-up
Blephroplasty (eye lift)
Allergies (If yes please list in the text box below)
Child birth within last 120 days
Allergy to Glycerin
Other Heath conditions/concerns that may affect your Lash Extension application
Allergies/ Other Health Conditions
If none, please indicate "none" or "N/A" in text area.
Please list any and all medications or vitamins you're currently taking. If none, please indicate "none" or "N/A" in text area.
Consent for Eyelash Procedure
I have agreed to have eyelash extensions applied to and/or removed from my eyelashes. 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 notwithstanding 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 when improperly handled. As part of this procedure, I understand that a certain amount of eyelash adhesive material will be used to attach the artificial lash extension to my existing eyelashes. Even though the Professional may apply or remove my lash extensions 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 lash extensions to my eyelashes, and I will not attribute any liability to Professional or the salon, as a result of this procedure or the use and care of these lashes. I also agree to defend, indemnify and hold harmless Professional and the salon from 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 “the salon” include all of their respective officers, directors, agents, employees, successors and assigns.
2. Waiver of Patch Test.
I understand the risks associated with lash extensions and I am willingly forgoing the patch test and accepting full responsibility of any and all reactions associated with the procedure
3. Care and Maintenance
I agree to follow the care and maintenance instructions provided by the Professional for the use and care of my lash extensions, 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 lash extensions 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 lash extensions. I will avoid getting my lashes wet within the first 24 hours after my application. I will avoid swimming, saunas or steam rooms within the first 48 hours after application. If I experience any itching or irritation, I agree to contact the Professional immediately to have the lash extensions removed. I will not use mascara (unless an approved product) or an eyelash curler, perm, or tint my lash extensions. I agree to not pick, pull or rub my lash 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.
4. No Known Medical Conditions/ Informed Consent
I have read and completed the 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 instructions or these warnings. If any action is brought to enforce the terms of this agreement, the prevailing party shall be entitled to its costs and reasonable attorneys’ fees. Any claims arising out of this agreement will be resolved through binding arbitration using the rules of the American Arbitration Association. This agreement will remain in effect for this procedure, and all future procedures conducted by the professional listed above or any other professional conducting business at the salon/spa establishment listed above. I agree that this agreement is binding upon me, and my heirs, legal representatives and assigns. I represent that I am over 18 years of age and that I have the right to enter this agreement.
5. Permission to Use Pictures.
I hereby grant to Professional 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 Professional. I further expressly assign any copyright in these photographs to the Professional. 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.
By submitting electronic signature below, I understand and adhere to all of the above.
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127 E Intercity Ave
Everett, WA 98208
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