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Lash Extension Waiver

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.
Waiver of Liability I understand there are risks associated with having artificial eyelashes applied to and/or removed from
my existing eyelashes, and that not withstanding the utmost of care in the application or removal of these products, there still
existing 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 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 GLOWOUT as a result of this procedure or the use and care of these lashes.
Care and Maintenance I agree to follow the care and maintenance instructions provided by GLOWOUT 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 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. For the first two days after application I understand it is best to avoid swimming, saunas or steam
rooms. If I experience any itching or irritation, I agree to contact GLOWOUT immediately to have the lash
extensions removed. I agree to avoid using mascara (unless it is extension safe) and to not use an eyelash curler, perm, or
tint my lash extensions. I agree to not pick, pull or rub lash extension. 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.


Lash Issues GLOWOUT offers the following salon policy regarding lash issues. If you have an issue within the
first 24 hours of your lash appointment, we will fix your lashes at no cost. I agree that I will contact GLOWOUT
immediately in the first 24 hours if I have excessive shedding or loss. I understand that past 24 hours any lash issues are a
result of care and maintenance issues.

Lash Fill Appointments I understand that it is my responsibility to come to my lash appointments on time and ready for my
service. I understand that it is expected that I come to my appointment completely makeup free. I understand that if I need
to remove makeup once arriving to the salon that I will arrive early to do so. I acknowledge that my appointment starts at
the time it is scheduled for and any time needed spent on face washing or running late will cut into time available to fill
my lashes.

No Known Medical Conditions / Informed Consent 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 3 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 or GLOWOUT instructions or these warnings
Cancellations and No Shows Please advise the following Salon Policy regarding Cancellations and No
Shows. Cancellations made in less than 12 hours prior to an appointment will be subject to a 50% charge of the service
that is booked. Clients who fail to show to an appointment will be charged our No-Show Fee of 100% charge of the service
that is booked.


Refunds GLOWOUT does not offer refunds on any service performed.
Photos I agree to have photos taken of me before, after and during my service. I understand that these photos may be
used for my own use to see the difference from my service as well as marketing purposes. I understand that all photo are
the rights of GLOWOUT and may be used on social media and our website.
GLOWOUT Communication As a client of GLOWOUT, you will be signing up for email and text communication
regarding appointment reminders and salon news that can be stopped at any time.
This agreement will remain in effect for this procedure, and all future procedures conducted by GLOWOUT or any
other professional conducting business at the salon/spa establishment listed above.
I acknowledge that beauty treatments, the practice of skin care, lash extensions, and various other beauty
procedures is not an exact science and no specific guarantees can or have been made concerning the outcome.
I
understand that some clients experience more change and improvement than others. I understand and agree to
assume the following risks and hazards which may occur in connection with any particular treatment including but
not limited to: unsatisfactory results, soreness, poor healing, discomfort, redness, blistering, nerve damage,
scarring, infection, change in skin pigmentation, allergic reaction, muscle damage, and increased hair growth. I
understand that even though precautions may be taken in my treatment, not all risks can be known in advance.
Given the above, I understand that response to treatment varies on an individual basis and that specific results are
not guaranteed. Therefore, in consideration for any treatment received, I agree to unconditionally defend, hold
harmless and release from any and all liability the company and the individual that provided my treatment, the
insured, and any additional insureds, as well as any officers, directors, or employees of the above companies for
any condition or result, known or unknown, that may arise as a consequence of any treatment that I receive. I have
fully disclosed on my client intake form any medications, previous complications, or current conditions that may
affect my treatment. I understand and agree that any legal action of any kind related to any treatment I receive will
be limited to binding arbitration using a single arbitrator agreed to by both parties.

First Client's Name

First Name*

Middle Name

Last Name*

Phone*
First Client's Date of Birth*
First Client's Signature*
Second Client's Name

First Name*

Middle Name

Last Name*
Second Client's Date of Birth*
Third Client's Name

First Name*

Middle Name

Last Name*
Third Client's Date of Birth*
Fourth Client's Name

First Name*

Middle Name

Last Name*
Fourth Client's Date of Birth*
Fifth Client's Name

First Name*

Middle Name

Last Name*
Fifth Client's Date of Birth*
Sixth Client's Name

First Name*

Middle Name

Last Name*
Sixth Client's Date of Birth*
Seventh Client's Name

First Name*

Middle Name

Last Name*
Seventh Client's Date of Birth*
Eighth Client's Name

First Name*

Middle Name

Last Name*
Eighth Client's Date of Birth*
Ninth Client's Name

First Name*

Middle Name

Last Name*
Ninth Client's Date of Birth*
Tenth Client's Name

First Name*

Middle Name

Last Name*
Tenth Client's Date of Birth*
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

Emergency Contact's Name*

Emergency Contact's Phone Number*
Additional Information
Are you under the age of 18?*
No
Yes
Is this your first time getting lash extensions?*
No
Yes
Do you wear strip lashes or use a lash curler?*
No
Yes
Do you wear contacts?*
No
Yes
Do you have any allergies?*
No
Yes
Do you have/have you had any of the following? *
Skin condition around the eye area
Epilepsy
Styes
Blepharities
Eye Infection
Cysts in the eye area
Dry Eye Syndrome
Cataract
None
Do you use Retin-A / Retinol?*
No
Yes
What look are you going for? *
Thicker
Longer
Natural
Dramatic
How did you find us? *
Instagram
Facebook
Google
Yelp
Referral
Other
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.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
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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