Beauty Service Client Application Form

Name

First Name

Last Name

Email

Address

Street Address

City

State / Province

ZIP / Postal Code

Phone Number

Date

Health History - please list any allergies (inc. Cosmetic ingredients) or relevant medical conditions? (Include any medications used)

Are you allergic to acrylate/cyanoacrylate (bonding agent)?

Yes No

Have you ever had any of the following conditions?

Is there any other condition or significant information we need to know about that may affect you during or after this procedure?

I understand that lash extension, lift, and tint services carry an inherent risk of irritation to the eye area, including the eye itself, and may cause stinging, burning, or blurred vision if adhesive enters the eye or an allergic reaction occurs.

I Agree

I understand that irritation, itching, or burning may occur on the skin if it comes into contact with the bonding agent.

I Agree

I understand that should the bonding agent contact my eye, it will be flushed with water right away and I will be helped to seek medical attention immediately.

I Agree

I understand this is a semi-permanent procedure, since my natural lashes will keep growing and shedding normally, making touch-up or 'fill' appointments necessary to maintain the look achieved by replacing shed lashes. Most clients need a fill appointment every 2-3 weeks.

I Agree

I understand it is essential that I disclose all information requested in the Client Profile/Health History.

I Agree

I have disclosed all conditions and circumstances regarding my health history, medications I am taking, and any past reactions to products or medications.

I Agree

I understand that additional conditions may arise or be discovered during the procedure that could affect my ability to tolerate it.

I Agree

I consent to 'before and after' photos being taken for documentation and potential advertising or promotional purposes.

I Agree

I understand that if I have any concerns, I will raise them with my technician. I authorize my technician to perform the lash extension procedure we discussed and release them and their staff from any liability arising from this treatment. I have accurately answered the questions above, including all known allergies and any products or medications I currently use. I understand my technician will take every precaution to minimize or avoid adverse reactions. Should further questions or concerns arise about my treatment, I will consult my technician right away. I agree that this statement is a full disclosure and supersedes any prior verbal or written disclosures. I certify I have read and fully understood the paragraphs above and had the opportunity to have my questions answered. I understand the procedure and accept the risks. I do not hold my technician responsible for conditions present but undisclosed at the time of this procedure that may be affected by today's treatment.

I Agree I Do Not Agree

Signature

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Beauty Service Client Application Form

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