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Informed Consent & Client Health History
Although every precaution will be taken to ensure your safety and wellbeing before, during and after your lash extension application, please be aware of the following information and possible risks
Email
(Required)
Please check the box if you acknowledge:
(Required)
I understand that a full set of lash extensions can make the appearance of my own lashes about 30-50% thicker, and make my lashes appear 20-50% longer.
I understand that lash extension services have some inherent risk of irritation to the orbital eye area, including the eye itself, and could result in stinging and burning, blurry vision and potentialblindness should the adhesive enter the eye or should an allergic reaction occur.
I understand that some irritation, itching or burning may occur on the skin if the bonding agent comes into contact with it.
I understand that if the bonding agent comes into contact with my eye, my eye will be flushed with water and I will be assisted in seeking medical attention immediately.
I understand that this is a semi-permanent procedure, as my natural lashes will continue to grow and fall out normally, making touch-up or “fill” appointments necessary to maintain the original look achieved by replacing the lashes that have fallen out. Most clients require a fill appointment every 2-3 weeks.
I understand that while every attempt will be made to provide me with the length and fullness I have chosen, my final result may not be what I initially envisioned.
I understand that it is imperative that I disclose all of the information requested in the Client Profile/Health History.
I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications.
I understand that additional conditions could occur or be discovered during the procedure which could affect my ability to tolerate the procedure.
I consent to “before and after” photographs for the purpose of documentation, potential advertising and promotional purposes.
I understand that if I have any concerns, I will address these with my lash extension specialist. I give permission to my lash extension specialist to perform the lash extension procedure we have discussed, and will hold him/her and his/her staff harmless and nameless from any liability that may result from this treatment. I have accurately answered the questions above, including all known allergies, prescription drugs, or products I am currently ingesting or using topically. I understand my lash extension specialist will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult the lash extension specialist immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the lash extension specialist, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today.
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I acknowledge that I have read, understood, and agree to abide by the Client Policy. By typing my full name below, I provide my digital signature, which holds the same legal weight as a handwritten signature, indicating my acceptance of the terms and conditions outlined in the policy.
Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
Name
(Required)
First
Last
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Cell Phone
How should we contact you?
(Required)
Email
Cell Phone
When is the best time to contact you?
(Required)
Morning
Daytime
Evening
Emergency Contact Name
(Required)
First
Last
Emergency Contact Phone Number
(Required)
Please list any allergies you have ( including cosmetics/ingredients): (If none please put NA)
(Required)
Have you ever had a reaction to adhesive tape, topical creams, nails adhesives, or other topical products?
(Required)
Yes
No
Do you have any eye disease, condition or injury that has affected your hair/lash growth or loss?
(Required)
Yes
No
Please list all current medications you are taking (including over the counter herbs, vitamins, and supplements)
(Required)
Have you ever had any of these conditions? (Please click all that apply)
(Required)
Alopecia
Cold Sores
Intense Stress
Sensitive Eyes
Asthma
Conjunctivitis (Pink eye)
Leamy Eye
Stroke/TIA
Back Pain or Back Injury
Diabetes
Light Sensitivity
Thyroid Disease
Bell's Palsy
Dry Eye Syndrome
Migraines
Trichotillomania
Blepharitis
Eye Sties or Sores
Ocular Rosacea
Recent eye Surgery
Claustrophobia
Heroes of the Eye
Rosacea
Current Eye Irritation
None of the above
Are you pregnant or nursing?
(Required)
Yes
No
Do you wear contacts?
(Required)
Yes
No
Do you wear glasses?
(Required)
Yes
No
Have you ever has lash extensions?
(Required)
Yes
No
Have you ever had lash extensions removed?
(Required)
Yes
No
Have you ever used long lasting or waterproof cosmetics?
(Required)
Yes
No
Do you used Retin-A or Accutane?
(Required)
Yes
No
Do you go tanning (in salon, outdoor, or spray tan)?
(Required)
Yes
No
Have you ever had Botox, Juvederm, or any other injectables?
(Required)
Yes
No
Have you ever used Latisse or any other lash growing product?
(Required)
Yes
No
Which side do you most often sleep on?
(Required)
Right
Left
Stomach
Back
Which side do you most often sleep on?
(Required)
Right
Left
Stomach
Back
How fast do you feel your hair grows?
(Required)
Fast
Slow
Normal Rate
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