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Eyelash Extension Consent, Release and Waiver Of Liability Agreement, Client Questionnaire

I am aware of the ongoing Pandemic of COVID-19. By signing I am disclosing that I am NOT experiencing the following symptoms of Covid-19 which are COUGH, FEVER, or DIFFICULTY BREATHING. I have not been notified by Alberta Health Services to Isolate and I have not been in contact with individuals known to have tested positive for Covid-19 or who are awaiting results of a Covid-19 screening. I am obligated to notify Hell On Heels Beauty and/or cancel my appointment.                                                                                                            

                                                                                                                                          

In the event I test positive or develop symptoms of Covid-19 I understand I am required to disclose this information to the Owner of Hell On Heels Beauty, Angelica Deering.                                                               

I understand that Information about myself will only be requested by Alberta Health Services if a potential exposure occurs onsite.

I consent to have synthetic eyelash extensions attached to my natural eyelashes at Hell On Heels Beauty by Angelica Deering. The Service and its associated risks have been explained to me by the Service Provider in terms that I understand. The information was obtained from the Service providers Website and from the ability for myself, the Client or Guardian to ask the Service Provider for more information. The explanation included: (INITIAL EACH BOX)

The benefits of the Service;


The nature of the Service and how the Service will be performed; The types of materials and adhesives used during the Service; 


The most frequently occurring risks of the Service, and those risks which are unlikely to occur but which may involve serious consequences, including but not limited to the risk of experiencing: (a) Blepharitis and its associated symptoms, (b) an allergic reactions to the adhesive material used to attach the eyelash extensions to my natural eyelashes and to the synthetic eyelash material, (c) Traction Alopecia and its associated symptoms; (d) an eye injury due to synthetic and/or natural eyelashes falling on or into the eye; and (e) an eye or other injury occurring during the performance of the Service; 


How to properly care for the synthetic eyelashes applied during the Service; and  


How often I should expect to need to repeat the Service and the best methods for caring for the synthetic eyelashes after the Service is performed; and 


Factors that affect retention of eyelashes. 


.                                                                                                         

I consent to brow/lash perming and tinting (Now or in the future if I choose to) at Hell On Heels Beauty by Angelica Deering or another employee. The Service and its associated risks have been explained to me by the Service Provider in terms that I understand. The information was obtained from the Service providers Website and from the ability for myself, the Client or Guardian to ask the Service Provider for more information. I understand the risks associated with these services and in some cases they may include: blisters, rash,redness,dry eye, watery eyes, inflammation, more brittle lash hair. Refectocil tints also pose a rare or extreme side affect of vision change if the solution comes into contact with the eye. I understand that if I have any of the following conditions: eye allergies, eye infections, skin sensitivity, styes, chronic dry eye, and/or watery eyes, that lash perming(Lash lifts) and lash tinting is NOT recommended. Lash perming/tinting(Lash lift) is NOT available for those that have had Lasik (laser corrective eye surgery) done within the last 6-12 months 

               

I consent to facial hair removal on my face (Now or in the future if I choose to) at Hell On Heels Beauty by Angelica Deering or another employee. The Service and its associated risks have been explained to me by the Service Provider in terms that I understand. The information was obtained from the Service providers Website and from the ability for myself, the Client or Guardian to ask the Service Provider for more information. I understand the risks associated with these services and in some cases they may include: Pain (With any type of waxing, a small amount of pain is inevitable.)Redness and irritation. Facial waxing can also cause mild redness and irritation temporarily after use, Rashes, Temporary bumps, Ingrown hairs, Sun sensitivity, Allergic reactions, and Bleeding. I understand that I must follow the preprocedure and postprocedure steps set by the Service Provider.

 

I was given the opportunity to ask the Service Provider any questions I have regarding the Service(s) and I have had those questions answered to my satisfaction. Based on the foregoing, I hereby assume all of the risks associated with the Service(s), whether known or unknown, including, but not limited to, the risk of personal injury or property damage. As consideration for Angelica Deering and all employees performing the Service, I forever release Hell On Heels Beauty and his/her/its respective directors, officers, members, managers, employees, agents, contractors, attorneys, representatives, successors and assigns from any and all actions, claims, or demands that I, my assignees, heirs, next of kin, spouse, personal representatives and legal representatives now have, or may have in the future, for injury, death, or property damage, in any way related to the Service.

By initialing at the end of this paragraph, I grant Service Provider permission to reproduce, publish, distribute or otherwise use in any reasonable manner my name, photograph, likeness and statements, including, but not limited to, before and after pictures of my eyes and eyelashes, and face in connection with the promotion of the Service(s) or the products used in the Service (or other similar services and products) in all media, including without limitation, the internet, news articles, advertisements, or other electronic or printed materials. If my initials are not present at the end of this paragraph, then the above-described permission has not been granted.

Photograph Release Approval


Artist Guarantee: I guarantee my work when all pre-procedure and post-procedure steps are followed. If you have issues with retention within the first 48 hours, I will fix the lash set at no extra charge to you. This is a policy that I am confident to offer.

Refunds: I do not offer refunds on services. I do however offer a 48 hour guarantee on all my services. If you have an adverse reaction to the lashes and are unable to wear the eyelash extensions that were applied, I will remove them free of charge. 


Allergies: If you experience an allergic reaction to any of the products used during the service, please contact me immediately for assistance in assessing the situation. I will advise you to seek medical attention as I am not a doctor. If you have not had any of the following: lash extension adhesive applied to your lashes prior, brow/lash perming solutions, brow/lash tints, and or waxing compounds, it is imperative that you have a patch test done and by initialing this you admit to having done so with no adverse effects.  


Reviews: I appreciate reviews and willingly accept feedback from clients. You agree to contact me and resolve issues privately and not to post negative feedback towards my business Hell On Heels Beauty and the Owner, Angelica Deering. I am very accommodating and successful in conflict/resolution. 


Cancellations/Missed Appointments/ Late Arrival: I require 24 hours notice for Appointments booked Monday thru Friday. For weekend appointments I require 72 hours. If you are cancelling last minute you will be required to book with a credit card for future appointments and a 50% deposit will need to be paid by said credit card or another method of payment. (THE FOLLOWING REMAINS THE SAME)The fee for a no-show for your rescheduled appointment, will be 50% of the original cost of the appointment before any promotions. All apointments will be rescheduled if you are late more than 5 mins. Unless you call and receive approval directly from A Hell On Heels Beauty Artist. 


 

 

BY SIGNING THIS FORM YOU (The Client) UNDERSTAND AND AGREE TO ALL THE INFORMATION IN THIS DOCUMENT. YOU ALSO ACKNOWLEDGE YOU HAVE READ THE PRE-PROCEDURE AND POST-PROCEDURE STEPS.

Today's Date: May 19, 2024


First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information
Have you had eyelash extensions applied before ?*
No
Yes

If yes, why did you remove them?
Do you wear contact lenses?*
No
Yes
Do you wear glasses?*
No
Yes
Do you have frequent eye irritation, itching, or watery eyes?*
No
Yes
Have you had eye surgery around your eyes in the last six months?*
No
Yes

Eyelash extensions require medical tape and adhesives that may contain acrylic or latex. 

Are you allergic to latex?*
No
Yes
Are you allergic to acrylic?*
No
Yes
PLEASE CHECK ANY OF THE FOLLOWING THAT MAY APPLY TO YOU
Eye surgery
Eye illness or injury
Dry eyes
Seasonal allergies
Eye infection
Permanent eye make-up
Blepharoplasty
Blepharitis (inflammation of eyelids)
Allergies to adhesives found in band-aids or medical tape
Allergies to cyanoacrylate adhesives (i.e. surgical glue, nail glue, crazy glue)
Hypersensitivity to formaldehyde ( a by-product released in cyanoacrylate adhesives)
Retinoids used to treat acne and skin problems (such as accutane or retin a)
Hormone imbalance
Recent severe illness or injury
Pregnancy or recent childbirth
New prescriptions or recently prescribed oral contraceptives
Types of medical conditions that may contribute to hair and eyelash loss: hyperthyroidism or hypothyroidism, alopecia areata, lupus, diabetes
Vitamin and mineral deficiencies that may contribute to hair and eyelash loss: A, F, B, Selenium, Zinc, Iron
Trichotillomania (hair pulling disorder)
Medications that may contribute to hair or eyelash loss: chemotherapeutic agents used in cancer treatment, Anticoagulants (blood thinners), beta blockers (used to control blood pressure)

Other Medical Information that may be beneficial to know such as suffering from anxiety etc. This information is CONFIDENTIAL but it helps me provide better care for you during your appointment. Whether it be extra pillows, a waited blanket, gentle music, etc. I want your experience to be stress free.
Have you ever had any of the following services?
Brow Lamination (Brow Perming)
Lash Lift (Lash Perming)
Lash/Brow Tinting
Did you have any adverse reactions?*
No
Yes

If you checked "YES" Please explain
If you have never had Brow Lamination, or a Lash Lift done, are you interested in more information?*
YES!
No
N/A

Have you had Covid-19? (Presumptive or Confirmed) If yes, what date? (Please refrain from booking with me until you are 5 days post symptoms.) *
First Client's Signature*
Second Client's Name

First Name*

Last Name*

Phone*
Second Client's Date of Birth*
Second Client's Information
Have you had eyelash extensions applied before ?*
No
Yes

If yes, why did you remove them?
Do you wear contact lenses?*
No
Yes
Do you wear glasses?*
No
Yes
Do you have frequent eye irritation, itching, or watery eyes?*
No
Yes
Have you had eye surgery around your eyes in the last six months?*
No
Yes

Eyelash extensions require medical tape and adhesives that may contain acrylic or latex. 

Are you allergic to latex?*
No
Yes
Are you allergic to acrylic?*
No
Yes
PLEASE CHECK ANY OF THE FOLLOWING THAT MAY APPLY TO YOU
Eye surgery
Eye illness or injury
Dry eyes
Seasonal allergies
Eye infection
Permanent eye make-up
Blepharoplasty
Blepharitis (inflammation of eyelids)
Allergies to adhesives found in band-aids or medical tape
Allergies to cyanoacrylate adhesives (i.e. surgical glue, nail glue, crazy glue)
Hypersensitivity to formaldehyde ( a by-product released in cyanoacrylate adhesives)
Retinoids used to treat acne and skin problems (such as accutane or retin a)
Hormone imbalance
Recent severe illness or injury
Pregnancy or recent childbirth
New prescriptions or recently prescribed oral contraceptives
Types of medical conditions that may contribute to hair and eyelash loss: hyperthyroidism or hypothyroidism, alopecia areata, lupus, diabetes
Vitamin and mineral deficiencies that may contribute to hair and eyelash loss: A, F, B, Selenium, Zinc, Iron
Trichotillomania (hair pulling disorder)
Medications that may contribute to hair or eyelash loss: chemotherapeutic agents used in cancer treatment, Anticoagulants (blood thinners), beta blockers (used to control blood pressure)

Other Medical Information that may be beneficial to know such as suffering from anxiety etc. This information is CONFIDENTIAL but it helps me provide better care for you during your appointment. Whether it be extra pillows, a waited blanket, gentle music, etc. I want your experience to be stress free.
Have you ever had any of the following services?
Brow Lamination (Brow Perming)
Lash Lift (Lash Perming)
Lash/Brow Tinting
Did you have any adverse reactions?*
No
Yes

If you checked "YES" Please explain
If you have never had Brow Lamination, or a Lash Lift done, are you interested in more information?*
YES!
No
N/A

Have you had Covid-19? (Presumptive or Confirmed) If yes, what date? (Please refrain from booking with me until you are 5 days post symptoms.) *
Third Client's Name

First Name*

Last Name*

Phone*
Third Client's Date of Birth*
Third Client's Information
Have you had eyelash extensions applied before ?*
No
Yes

If yes, why did you remove them?
Do you wear contact lenses?*
No
Yes
Do you wear glasses?*
No
Yes
Do you have frequent eye irritation, itching, or watery eyes?*
No
Yes
Have you had eye surgery around your eyes in the last six months?*
No
Yes

Eyelash extensions require medical tape and adhesives that may contain acrylic or latex. 

Are you allergic to latex?*
No
Yes
Are you allergic to acrylic?*
No
Yes
PLEASE CHECK ANY OF THE FOLLOWING THAT MAY APPLY TO YOU
Eye surgery
Eye illness or injury
Dry eyes
Seasonal allergies
Eye infection
Permanent eye make-up
Blepharoplasty
Blepharitis (inflammation of eyelids)
Allergies to adhesives found in band-aids or medical tape
Allergies to cyanoacrylate adhesives (i.e. surgical glue, nail glue, crazy glue)
Hypersensitivity to formaldehyde ( a by-product released in cyanoacrylate adhesives)
Retinoids used to treat acne and skin problems (such as accutane or retin a)
Hormone imbalance
Recent severe illness or injury
Pregnancy or recent childbirth
New prescriptions or recently prescribed oral contraceptives
Types of medical conditions that may contribute to hair and eyelash loss: hyperthyroidism or hypothyroidism, alopecia areata, lupus, diabetes
Vitamin and mineral deficiencies that may contribute to hair and eyelash loss: A, F, B, Selenium, Zinc, Iron
Trichotillomania (hair pulling disorder)
Medications that may contribute to hair or eyelash loss: chemotherapeutic agents used in cancer treatment, Anticoagulants (blood thinners), beta blockers (used to control blood pressure)

Other Medical Information that may be beneficial to know such as suffering from anxiety etc. This information is CONFIDENTIAL but it helps me provide better care for you during your appointment. Whether it be extra pillows, a waited blanket, gentle music, etc. I want your experience to be stress free.
Have you ever had any of the following services?
Brow Lamination (Brow Perming)
Lash Lift (Lash Perming)
Lash/Brow Tinting
Did you have any adverse reactions?*
No
Yes

If you checked "YES" Please explain
If you have never had Brow Lamination, or a Lash Lift done, are you interested in more information?*
YES!
No
N/A

Have you had Covid-19? (Presumptive or Confirmed) If yes, what date? (Please refrain from booking with me until you are 5 days post symptoms.) *
Fourth Client's Name

First Name*

Last Name*

Phone*
Fourth Client's Date of Birth*
Fourth Client's Information
Have you had eyelash extensions applied before ?*
No
Yes

If yes, why did you remove them?
Do you wear contact lenses?*
No
Yes
Do you wear glasses?*
No
Yes
Do you have frequent eye irritation, itching, or watery eyes?*
No
Yes
Have you had eye surgery around your eyes in the last six months?*
No
Yes

Eyelash extensions require medical tape and adhesives that may contain acrylic or latex. 

Are you allergic to latex?*
No
Yes
Are you allergic to acrylic?*
No
Yes
PLEASE CHECK ANY OF THE FOLLOWING THAT MAY APPLY TO YOU
Eye surgery
Eye illness or injury
Dry eyes
Seasonal allergies
Eye infection
Permanent eye make-up
Blepharoplasty
Blepharitis (inflammation of eyelids)
Allergies to adhesives found in band-aids or medical tape
Allergies to cyanoacrylate adhesives (i.e. surgical glue, nail glue, crazy glue)
Hypersensitivity to formaldehyde ( a by-product released in cyanoacrylate adhesives)
Retinoids used to treat acne and skin problems (such as accutane or retin a)
Hormone imbalance
Recent severe illness or injury
Pregnancy or recent childbirth
New prescriptions or recently prescribed oral contraceptives
Types of medical conditions that may contribute to hair and eyelash loss: hyperthyroidism or hypothyroidism, alopecia areata, lupus, diabetes
Vitamin and mineral deficiencies that may contribute to hair and eyelash loss: A, F, B, Selenium, Zinc, Iron
Trichotillomania (hair pulling disorder)
Medications that may contribute to hair or eyelash loss: chemotherapeutic agents used in cancer treatment, Anticoagulants (blood thinners), beta blockers (used to control blood pressure)

Other Medical Information that may be beneficial to know such as suffering from anxiety etc. This information is CONFIDENTIAL but it helps me provide better care for you during your appointment. Whether it be extra pillows, a waited blanket, gentle music, etc. I want your experience to be stress free.
Have you ever had any of the following services?
Brow Lamination (Brow Perming)
Lash Lift (Lash Perming)
Lash/Brow Tinting
Did you have any adverse reactions?*
No
Yes

If you checked "YES" Please explain
If you have never had Brow Lamination, or a Lash Lift done, are you interested in more information?*
YES!
No
N/A

Have you had Covid-19? (Presumptive or Confirmed) If yes, what date? (Please refrain from booking with me until you are 5 days post symptoms.) *
Fifth Client's Name

First Name*

Last Name*

Phone*
Fifth Client's Date of Birth*
Fifth Client's Information
Have you had eyelash extensions applied before ?*
No
Yes

If yes, why did you remove them?
Do you wear contact lenses?*
No
Yes
Do you wear glasses?*
No
Yes
Do you have frequent eye irritation, itching, or watery eyes?*
No
Yes
Have you had eye surgery around your eyes in the last six months?*
No
Yes

Eyelash extensions require medical tape and adhesives that may contain acrylic or latex. 

Are you allergic to latex?*
No
Yes
Are you allergic to acrylic?*
No
Yes
PLEASE CHECK ANY OF THE FOLLOWING THAT MAY APPLY TO YOU
Eye surgery
Eye illness or injury
Dry eyes
Seasonal allergies
Eye infection
Permanent eye make-up
Blepharoplasty
Blepharitis (inflammation of eyelids)
Allergies to adhesives found in band-aids or medical tape
Allergies to cyanoacrylate adhesives (i.e. surgical glue, nail glue, crazy glue)
Hypersensitivity to formaldehyde ( a by-product released in cyanoacrylate adhesives)
Retinoids used to treat acne and skin problems (such as accutane or retin a)
Hormone imbalance
Recent severe illness or injury
Pregnancy or recent childbirth
New prescriptions or recently prescribed oral contraceptives
Types of medical conditions that may contribute to hair and eyelash loss: hyperthyroidism or hypothyroidism, alopecia areata, lupus, diabetes
Vitamin and mineral deficiencies that may contribute to hair and eyelash loss: A, F, B, Selenium, Zinc, Iron
Trichotillomania (hair pulling disorder)
Medications that may contribute to hair or eyelash loss: chemotherapeutic agents used in cancer treatment, Anticoagulants (blood thinners), beta blockers (used to control blood pressure)

Other Medical Information that may be beneficial to know such as suffering from anxiety etc. This information is CONFIDENTIAL but it helps me provide better care for you during your appointment. Whether it be extra pillows, a waited blanket, gentle music, etc. I want your experience to be stress free.
Have you ever had any of the following services?
Brow Lamination (Brow Perming)
Lash Lift (Lash Perming)
Lash/Brow Tinting
Did you have any adverse reactions?*
No
Yes

If you checked "YES" Please explain
If you have never had Brow Lamination, or a Lash Lift done, are you interested in more information?*
YES!
No
N/A

Have you had Covid-19? (Presumptive or Confirmed) If yes, what date? (Please refrain from booking with me until you are 5 days post symptoms.) *
Sixth Client's Name

First Name*

Last Name*

Phone*
Sixth Client's Date of Birth*
Sixth Client's Information
Have you had eyelash extensions applied before ?*
No
Yes

If yes, why did you remove them?
Do you wear contact lenses?*
No
Yes
Do you wear glasses?*
No
Yes
Do you have frequent eye irritation, itching, or watery eyes?*
No
Yes
Have you had eye surgery around your eyes in the last six months?*
No
Yes

Eyelash extensions require medical tape and adhesives that may contain acrylic or latex. 

Are you allergic to latex?*
No
Yes
Are you allergic to acrylic?*
No
Yes
PLEASE CHECK ANY OF THE FOLLOWING THAT MAY APPLY TO YOU
Eye surgery
Eye illness or injury
Dry eyes
Seasonal allergies
Eye infection
Permanent eye make-up
Blepharoplasty
Blepharitis (inflammation of eyelids)
Allergies to adhesives found in band-aids or medical tape
Allergies to cyanoacrylate adhesives (i.e. surgical glue, nail glue, crazy glue)
Hypersensitivity to formaldehyde ( a by-product released in cyanoacrylate adhesives)
Retinoids used to treat acne and skin problems (such as accutane or retin a)
Hormone imbalance
Recent severe illness or injury
Pregnancy or recent childbirth
New prescriptions or recently prescribed oral contraceptives
Types of medical conditions that may contribute to hair and eyelash loss: hyperthyroidism or hypothyroidism, alopecia areata, lupus, diabetes
Vitamin and mineral deficiencies that may contribute to hair and eyelash loss: A, F, B, Selenium, Zinc, Iron
Trichotillomania (hair pulling disorder)
Medications that may contribute to hair or eyelash loss: chemotherapeutic agents used in cancer treatment, Anticoagulants (blood thinners), beta blockers (used to control blood pressure)

Other Medical Information that may be beneficial to know such as suffering from anxiety etc. This information is CONFIDENTIAL but it helps me provide better care for you during your appointment. Whether it be extra pillows, a waited blanket, gentle music, etc. I want your experience to be stress free.
Have you ever had any of the following services?
Brow Lamination (Brow Perming)
Lash Lift (Lash Perming)
Lash/Brow Tinting
Did you have any adverse reactions?*
No
Yes

If you checked "YES" Please explain
If you have never had Brow Lamination, or a Lash Lift done, are you interested in more information?*
YES!
No
N/A

Have you had Covid-19? (Presumptive or Confirmed) If yes, what date? (Please refrain from booking with me until you are 5 days post symptoms.) *
Seventh Client's Name

First Name*

Last Name*

Phone*
Seventh Client's Date of Birth*
Seventh Client's Information
Have you had eyelash extensions applied before ?*
No
Yes

If yes, why did you remove them?
Do you wear contact lenses?*
No
Yes
Do you wear glasses?*
No
Yes
Do you have frequent eye irritation, itching, or watery eyes?*
No
Yes
Have you had eye surgery around your eyes in the last six months?*
No
Yes

Eyelash extensions require medical tape and adhesives that may contain acrylic or latex. 

Are you allergic to latex?*
No
Yes
Are you allergic to acrylic?*
No
Yes
PLEASE CHECK ANY OF THE FOLLOWING THAT MAY APPLY TO YOU
Eye surgery
Eye illness or injury
Dry eyes
Seasonal allergies
Eye infection
Permanent eye make-up
Blepharoplasty
Blepharitis (inflammation of eyelids)
Allergies to adhesives found in band-aids or medical tape
Allergies to cyanoacrylate adhesives (i.e. surgical glue, nail glue, crazy glue)
Hypersensitivity to formaldehyde ( a by-product released in cyanoacrylate adhesives)
Retinoids used to treat acne and skin problems (such as accutane or retin a)
Hormone imbalance
Recent severe illness or injury
Pregnancy or recent childbirth
New prescriptions or recently prescribed oral contraceptives
Types of medical conditions that may contribute to hair and eyelash loss: hyperthyroidism or hypothyroidism, alopecia areata, lupus, diabetes
Vitamin and mineral deficiencies that may contribute to hair and eyelash loss: A, F, B, Selenium, Zinc, Iron
Trichotillomania (hair pulling disorder)
Medications that may contribute to hair or eyelash loss: chemotherapeutic agents used in cancer treatment, Anticoagulants (blood thinners), beta blockers (used to control blood pressure)

Other Medical Information that may be beneficial to know such as suffering from anxiety etc. This information is CONFIDENTIAL but it helps me provide better care for you during your appointment. Whether it be extra pillows, a waited blanket, gentle music, etc. I want your experience to be stress free.
Have you ever had any of the following services?
Brow Lamination (Brow Perming)
Lash Lift (Lash Perming)
Lash/Brow Tinting
Did you have any adverse reactions?*
No
Yes

If you checked "YES" Please explain
If you have never had Brow Lamination, or a Lash Lift done, are you interested in more information?*
YES!
No
N/A

Have you had Covid-19? (Presumptive or Confirmed) If yes, what date? (Please refrain from booking with me until you are 5 days post symptoms.) *
Eighth Client's Name

First Name*

Last Name*

Phone*
Eighth Client's Date of Birth*
Eighth Client's Information
Have you had eyelash extensions applied before ?*
No
Yes

If yes, why did you remove them?
Do you wear contact lenses?*
No
Yes
Do you wear glasses?*
No
Yes
Do you have frequent eye irritation, itching, or watery eyes?*
No
Yes
Have you had eye surgery around your eyes in the last six months?*
No
Yes

Eyelash extensions require medical tape and adhesives that may contain acrylic or latex. 

Are you allergic to latex?*
No
Yes
Are you allergic to acrylic?*
No
Yes
PLEASE CHECK ANY OF THE FOLLOWING THAT MAY APPLY TO YOU
Eye surgery
Eye illness or injury
Dry eyes
Seasonal allergies
Eye infection
Permanent eye make-up
Blepharoplasty
Blepharitis (inflammation of eyelids)
Allergies to adhesives found in band-aids or medical tape
Allergies to cyanoacrylate adhesives (i.e. surgical glue, nail glue, crazy glue)
Hypersensitivity to formaldehyde ( a by-product released in cyanoacrylate adhesives)
Retinoids used to treat acne and skin problems (such as accutane or retin a)
Hormone imbalance
Recent severe illness or injury
Pregnancy or recent childbirth
New prescriptions or recently prescribed oral contraceptives
Types of medical conditions that may contribute to hair and eyelash loss: hyperthyroidism or hypothyroidism, alopecia areata, lupus, diabetes
Vitamin and mineral deficiencies that may contribute to hair and eyelash loss: A, F, B, Selenium, Zinc, Iron
Trichotillomania (hair pulling disorder)
Medications that may contribute to hair or eyelash loss: chemotherapeutic agents used in cancer treatment, Anticoagulants (blood thinners), beta blockers (used to control blood pressure)

Other Medical Information that may be beneficial to know such as suffering from anxiety etc. This information is CONFIDENTIAL but it helps me provide better care for you during your appointment. Whether it be extra pillows, a waited blanket, gentle music, etc. I want your experience to be stress free.
Have you ever had any of the following services?
Brow Lamination (Brow Perming)
Lash Lift (Lash Perming)
Lash/Brow Tinting
Did you have any adverse reactions?*
No
Yes

If you checked "YES" Please explain
If you have never had Brow Lamination, or a Lash Lift done, are you interested in more information?*
YES!
No
N/A

Have you had Covid-19? (Presumptive or Confirmed) If yes, what date? (Please refrain from booking with me until you are 5 days post symptoms.) *
Ninth Client's Name

First Name*

Last Name*

Phone*
Ninth Client's Date of Birth*
Ninth Client's Information
Have you had eyelash extensions applied before ?*
No
Yes

If yes, why did you remove them?
Do you wear contact lenses?*
No
Yes
Do you wear glasses?*
No
Yes
Do you have frequent eye irritation, itching, or watery eyes?*
No
Yes
Have you had eye surgery around your eyes in the last six months?*
No
Yes

Eyelash extensions require medical tape and adhesives that may contain acrylic or latex. 

Are you allergic to latex?*
No
Yes
Are you allergic to acrylic?*
No
Yes
PLEASE CHECK ANY OF THE FOLLOWING THAT MAY APPLY TO YOU
Eye surgery
Eye illness or injury
Dry eyes
Seasonal allergies
Eye infection
Permanent eye make-up
Blepharoplasty
Blepharitis (inflammation of eyelids)
Allergies to adhesives found in band-aids or medical tape
Allergies to cyanoacrylate adhesives (i.e. surgical glue, nail glue, crazy glue)
Hypersensitivity to formaldehyde ( a by-product released in cyanoacrylate adhesives)
Retinoids used to treat acne and skin problems (such as accutane or retin a)
Hormone imbalance
Recent severe illness or injury
Pregnancy or recent childbirth
New prescriptions or recently prescribed oral contraceptives
Types of medical conditions that may contribute to hair and eyelash loss: hyperthyroidism or hypothyroidism, alopecia areata, lupus, diabetes
Vitamin and mineral deficiencies that may contribute to hair and eyelash loss: A, F, B, Selenium, Zinc, Iron
Trichotillomania (hair pulling disorder)
Medications that may contribute to hair or eyelash loss: chemotherapeutic agents used in cancer treatment, Anticoagulants (blood thinners), beta blockers (used to control blood pressure)

Other Medical Information that may be beneficial to know such as suffering from anxiety etc. This information is CONFIDENTIAL but it helps me provide better care for you during your appointment. Whether it be extra pillows, a waited blanket, gentle music, etc. I want your experience to be stress free.
Have you ever had any of the following services?
Brow Lamination (Brow Perming)
Lash Lift (Lash Perming)
Lash/Brow Tinting
Did you have any adverse reactions?*
No
Yes

If you checked "YES" Please explain
If you have never had Brow Lamination, or a Lash Lift done, are you interested in more information?*
YES!
No
N/A

Have you had Covid-19? (Presumptive or Confirmed) If yes, what date? (Please refrain from booking with me until you are 5 days post symptoms.) *
Tenth Client's Name

First Name*

Last Name*

Phone*
Tenth Client's Date of Birth*
Tenth Client's Information
Have you had eyelash extensions applied before ?*
No
Yes

If yes, why did you remove them?
Do you wear contact lenses?*
No
Yes
Do you wear glasses?*
No
Yes
Do you have frequent eye irritation, itching, or watery eyes?*
No
Yes
Have you had eye surgery around your eyes in the last six months?*
No
Yes

Eyelash extensions require medical tape and adhesives that may contain acrylic or latex. 

Are you allergic to latex?*
No
Yes
Are you allergic to acrylic?*
No
Yes
PLEASE CHECK ANY OF THE FOLLOWING THAT MAY APPLY TO YOU
Eye surgery
Eye illness or injury
Dry eyes
Seasonal allergies
Eye infection
Permanent eye make-up
Blepharoplasty
Blepharitis (inflammation of eyelids)
Allergies to adhesives found in band-aids or medical tape
Allergies to cyanoacrylate adhesives (i.e. surgical glue, nail glue, crazy glue)
Hypersensitivity to formaldehyde ( a by-product released in cyanoacrylate adhesives)
Retinoids used to treat acne and skin problems (such as accutane or retin a)
Hormone imbalance
Recent severe illness or injury
Pregnancy or recent childbirth
New prescriptions or recently prescribed oral contraceptives
Types of medical conditions that may contribute to hair and eyelash loss: hyperthyroidism or hypothyroidism, alopecia areata, lupus, diabetes
Vitamin and mineral deficiencies that may contribute to hair and eyelash loss: A, F, B, Selenium, Zinc, Iron
Trichotillomania (hair pulling disorder)
Medications that may contribute to hair or eyelash loss: chemotherapeutic agents used in cancer treatment, Anticoagulants (blood thinners), beta blockers (used to control blood pressure)

Other Medical Information that may be beneficial to know such as suffering from anxiety etc. This information is CONFIDENTIAL but it helps me provide better care for you during your appointment. Whether it be extra pillows, a waited blanket, gentle music, etc. I want your experience to be stress free.
Have you ever had any of the following services?
Brow Lamination (Brow Perming)
Lash Lift (Lash Perming)
Lash/Brow Tinting
Did you have any adverse reactions?*
No
Yes

If you checked "YES" Please explain
If you have never had Brow Lamination, or a Lash Lift done, are you interested in more information?*
YES!
No
N/A

Have you had Covid-19? (Presumptive or Confirmed) If yes, what date? (Please refrain from booking with me until you are 5 days post symptoms.) *
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Appointment Details

APPOINTMENT DATE *

APPOINTMENT TIME *
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Have you had eyelash extensions applied before ?*
No
Yes

If yes, why did you remove them?
Do you wear contact lenses?*
No
Yes
Do you wear glasses?*
No
Yes
Do you have frequent eye irritation, itching, or watery eyes?*
No
Yes
Have you had eye surgery around your eyes in the last six months?*
No
Yes

Eyelash extensions require medical tape and adhesives that may contain acrylic or latex. 

Are you allergic to latex?*
No
Yes
Are you allergic to acrylic?*
No
Yes
PLEASE CHECK ANY OF THE FOLLOWING THAT MAY APPLY TO YOU
Eye surgery
Eye illness or injury
Dry eyes
Seasonal allergies
Eye infection
Permanent eye make-up
Blepharoplasty
Blepharitis (inflammation of eyelids)
Allergies to adhesives found in band-aids or medical tape
Allergies to cyanoacrylate adhesives (i.e. surgical glue, nail glue, crazy glue)
Hypersensitivity to formaldehyde ( a by-product released in cyanoacrylate adhesives)
Retinoids used to treat acne and skin problems (such as accutane or retin a)
Hormone imbalance
Recent severe illness or injury
Pregnancy or recent childbirth
New prescriptions or recently prescribed oral contraceptives
Types of medical conditions that may contribute to hair and eyelash loss: hyperthyroidism or hypothyroidism, alopecia areata, lupus, diabetes
Vitamin and mineral deficiencies that may contribute to hair and eyelash loss: A, F, B, Selenium, Zinc, Iron
Trichotillomania (hair pulling disorder)
Medications that may contribute to hair or eyelash loss: chemotherapeutic agents used in cancer treatment, Anticoagulants (blood thinners), beta blockers (used to control blood pressure)

Other Medical Information that may be beneficial to know such as suffering from anxiety etc. This information is CONFIDENTIAL but it helps me provide better care for you during your appointment. Whether it be extra pillows, a waited blanket, gentle music, etc. I want your experience to be stress free.
Have you ever had any of the following services?
Brow Lamination (Brow Perming)
Lash Lift (Lash Perming)
Lash/Brow Tinting
Did you have any adverse reactions?*
No
Yes

If you checked "YES" Please explain
If you have never had Brow Lamination, or a Lash Lift done, are you interested in more information?*
YES!
No
N/A

Have you had Covid-19? (Presumptive or Confirmed) If yes, what date? (Please refrain from booking with me until you are 5 days post symptoms.) *
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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