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Eyelash Extension Consent Form

Artist Information (the “Artist”):
Amber Groves
74 Glenhill Place, Cochrane, AB T4C 1H1

By signing this agreement, I acknowledge that I have been given the full opportunity to ask any and all questions, which I might have about the Eyelash Extension Application (the “Procedure”) and that all of my questions have been answered to my full satisfaction, by the Artist as named above, who will be performing the Procedure. I specifically acknowledge that I have been advised of the facts and matters set forth below.

I am over the age of eighteen (18) and I have truthfully represented to the Artist that undergoing the Procedure is by my choice alone.

I Agree

I understand that the Procedure is risky and I am having it done at my own risk. I am not under the influence of drugs or alcohol.

I Agree

I do not have eye conditions such as a sty, chalazia, mole or any other skin sensitiveness in the Procedure area.

I Agree

I do not currently have cancer. I am not undergoing chemotherapy and I have not undergone chemotherapy in the past 12 months. 

I Agree

I do not have any sensitivity or allergy to cyanoacrylate, formaldehyde, any adhesives or glues.

I Agree

I have received the aftercare instructions and I agree to follow them. I also agree that if I do not follow the instructions, any touch-up needed will be done at my own expense.

I Agree

I consent to have the Artist perform the Procedure and also any actions or conduct that are reasonably necessary to perform the Procedure.

I Agree

I acknowledge that:

I might have an allergic reaction to the adhesives or any of the products used in the Procedure, and this reaction can occur at any time and I accept the risk that such a reaction is possible.

I Agree

The Procedure will result in semi-permanent change to my appearance (which usually lasts between 2 and 5 weeks) and that no representation has been made to me as the ability to later change or remove these results on my own.

I Agree

Liability 
The Client acknowledges that the Artist will take all necessary precautions to protect the Client during the Procedure and that the Artist is not a medical professional even if they carry a secondary designation as a registered massage therapist (RMT). The Procedure is not within the scope of practice of a RMT.

The Artist shall not be liable for any direct, indirect, special, consequential, or exemplary damages or injury to the Client resulting from, or in any way connecting to the Procedure.

I Agree.
(Client initials)

Risks
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 exist risks associated with the Procedure and product itself, which include, without limitation, eye irritation, eye pain, discomfort, and, in rare cases, blindness even when applied in the usual manner.

If I experience any irritation, redness, puffiness, itchiness, an allergic reaction or any other side effect of this procedure, I will contact a medical doctor immediately.

As part of the Procedure, I understand that a certain amount of eyelash adhesive material will be used to attach the artificial eyelashes to my existing eyelashes. Even though the eyelash extension artist may apply or remove my eyelash extensions in the usual manner, 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 eyelash extensions to my eyelashes, and I will not attribute any liability to the eyelash extension artist as a result of this procedure or the use and care of these lashes.

As part of the removal Procedure, I understand that a certain amount of chemical adhesive remover is applied to existing adhesives and a reaction occurs to dissolve the adhesive that results in the thinning of the remover. Even though the eyelash extension artist may apply or remove my eyelash extensions in the usual manner, I understand the liquid remover may seep into my eyes, which may irritate my eyes or require further follow-up care, at my own expense to prevent damage to my eyes.

I am fully aware that the Procedure is inherently dangerous and that such Procedure is subject to mishap, injury and possibly even death.

I acknowledge that no warranties, either express or implied, have been given concerning the safety of the Procedure or the skills of the Artist.

I Agree.
(Client initials) 

Release
The Client hereby releases the Artist, its principals, agents, and employees, from any and all liability, actions, causes of action, claims, loss, demands, damages, or injury, including legal costs, loss of profit, or other special or consequential damages, howsoever arising, which the Client now has or which hereinafter may have, against the Artist by reason of or in any way related to the Procedure.

The Client agrees to indemnify and hold harmless the Artist, its principals, agents, and employees from any and all liability, actions, causes of action, claims, loss, demands, damages, or injury, including legal costs, loss of profit, or other special or consequential damages, or injury, including legal costs, loss of profit, or other special or consequential damages, howsoever arising, resulting from, or in any way connected to, the Procedure, or my purchase of products from her.

I Agree.
(Client initials)

Care and Maintenance
I agree to follow the care and maintenance instructions provided by the Artist for the care of the Procedure area following the Procedure, 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 failure to follow aftercare instructions may result in permanent damage to my eyelash extensions, natural eyelashes, eyelids and eye area. I agree to keep the Procedure area clean and to follow aftercare instructions. I understand that if I pick, pull on, or rub my eyelash extensions it may result in the premature temporary and permanent loss of my artificial and natural eyelashes.

I also understand that eyelash extension retention varies for each client and is dependent on many factors that are not within the control of the Artist. The Artist will take all necessary actions to ensure the longest possible retention of eyelash extensions for the Client, however eyelash extension retention time is not guaranteed. Fill appointments are necessary to maintain the optimal look of the eyelash extensions. The frequencies of necessary fill appointments are individual and should not be compared with any other person’s eyelash extension fill appointment scheduling.

I Agree.
(Client initials)

No Known Medical Conditions / Informed Consent
I have read and completed the Procedure 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 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 amounts 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 Artist’s instructions or these warnings.

I Agree.
(Client initials)

Spot Test
I understand, that should I have any concerns about any possible reaction to the chemicals and products used, I may arrange at my own discretion to book an advance spot test where 2 to 3 individual lashes will be applied 24-48 hours prior to the time in which I’m scheduled for the Procedure. I also understand that spot testing does not guarantee that no future sensitivity or reactions will develop. I agree that scheduling a spot test shall be my own responsibility and at my sole discretion, and have absolutely no bearing on the contents or signing of this Agreement or any clauses contained therein. 

I Agree.
(Client initials)

Cancellation / Late Policy
I understand that the appointment time is reserved for the Client. A late cancellation or missed visit leaves a hole in the Artist's day that could have been filled by another client. The Artist requires 24 hours notice for any cancellations or changes to your appointment. If the Client provides less than 24 hours notice or misses their appointment, the Client will be charged a cancellation fee of the entire cost of the appointment as booked.

If the Client arrives late for their appointment, no additional time will be added to the appointment. The Procedure will be stopped at the scheduled end time of the appointment, regardless as to whether or not the desired outcome is achieved in the remaining amount of time. The client will be charged in full for the service time as booked.

I Agree.
(Client initials)

Permissions to Use Photographs
I hereby grant the Artist the full right to take, publish and reproduce photographs of me, my face, my eyes and/or eyebrows, 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 the Artist. I further expressly assign any copyright in these photographs to the Artist. I also grant my consent for the Artist to use my image and likeness as contained in these photographs for any advertising or other purposes

I Agree.
(Client initials) 

Children
I understand that the Procedure requires the full attention of the Client and the Artist. As such, unattended minor children are not permitted in the Procedure space during your appointment.

I Agree.
(Client initials)

Refunds
I understand that the Procedure and all services rendered by the Artist are non-refundable.

I Agree.
(Client initials) 

Design Approval
I approve of the eyelash extension selection, length, width and styling suggested by the Artist, and I have been given an opportunity to modify the suggestions prior to the Artist’s application.

I Agree.
(Client initials)

Declaration
The Client has read this entire document, understands its contents, and knows the truthfulness thereof.

I Agree.
(Client initials)

IN WITNESS WHEREOF the parties have signed, sealed and delivered this Agreement as of the date first above written.

Today's Date: September 20, 2020

 

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information

How did you hear about us? *
Is this your first time having eyelash extensions applied?*
Are you having your eyelash extensions applied for:*
In the last 60 days, have you worn:*
Do you do any of the following to your natural eyelashes?*

These procedures cannot be done once eyelash extensions have been applied. If you wish to curl, tint or perm your natural eyelashes, please do so prior to extension application.

Do you wear contact lenses?*
Do you have or are you being treated for any eye illness or injury?*

Eye Illness or injury details:

Please list any eye drops or eye medications that you use:
Are you able to keep your eyes closed comfortably for more than 2 hours?*
Please check any of the following that may apply to you:
Lasik eye surgery
Permanent eye make-up
Blephoplasty (eye lift)
Microdermabrasion
Childbirth within the last 120 days
Major surgery within the last 120 days
Alopecia**
Hypersensitivity to cyanoacrylate, formaldehyde, any adhesives or glues
Recent high fever or illness
Regular exposure to swimming pool chemicals, bleach or dyes
Drugs or medications that can cause temporary hair loss (Chemotheraputic drugs, Retinoids for acne treatment, Anticoagulants or Beta-adrenergic Blockers for blood pressure, etc)**
Allergies - please describe here

**Eyelash extensions cannot be bonded to skin. If you do not have natural eyelashes we cannot apply extensions. Alopecia sufferers or people taking medications that cause hair loss are not good candidates for this service.


Is there anything else you think we should know before you have your eyelash extensions applied?
First Client's Signature*
Second Client's Name

First Name*

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

How did you hear about us? *
Is this your first time having eyelash extensions applied?*
Are you having your eyelash extensions applied for:*
In the last 60 days, have you worn:*
Do you do any of the following to your natural eyelashes?*

These procedures cannot be done once eyelash extensions have been applied. If you wish to curl, tint or perm your natural eyelashes, please do so prior to extension application.

Do you wear contact lenses?*
Do you have or are you being treated for any eye illness or injury?*

Eye Illness or injury details:

Please list any eye drops or eye medications that you use:
Are you able to keep your eyes closed comfortably for more than 2 hours?*
Please check any of the following that may apply to you:
Lasik eye surgery
Permanent eye make-up
Blephoplasty (eye lift)
Microdermabrasion
Childbirth within the last 120 days
Major surgery within the last 120 days
Alopecia**
Hypersensitivity to cyanoacrylate, formaldehyde, any adhesives or glues
Recent high fever or illness
Regular exposure to swimming pool chemicals, bleach or dyes
Drugs or medications that can cause temporary hair loss (Chemotheraputic drugs, Retinoids for acne treatment, Anticoagulants or Beta-adrenergic Blockers for blood pressure, etc)**
Allergies - please describe here

**Eyelash extensions cannot be bonded to skin. If you do not have natural eyelashes we cannot apply extensions. Alopecia sufferers or people taking medications that cause hair loss are not good candidates for this service.


Is there anything else you think we should know before you have your eyelash extensions applied?
Third Client's Name

First Name*

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

How did you hear about us? *
Is this your first time having eyelash extensions applied?*
Are you having your eyelash extensions applied for:*
In the last 60 days, have you worn:*
Do you do any of the following to your natural eyelashes?*

These procedures cannot be done once eyelash extensions have been applied. If you wish to curl, tint or perm your natural eyelashes, please do so prior to extension application.

Do you wear contact lenses?*
Do you have or are you being treated for any eye illness or injury?*

Eye Illness or injury details:

Please list any eye drops or eye medications that you use:
Are you able to keep your eyes closed comfortably for more than 2 hours?*
Please check any of the following that may apply to you:
Lasik eye surgery
Permanent eye make-up
Blephoplasty (eye lift)
Microdermabrasion
Childbirth within the last 120 days
Major surgery within the last 120 days
Alopecia**
Hypersensitivity to cyanoacrylate, formaldehyde, any adhesives or glues
Recent high fever or illness
Regular exposure to swimming pool chemicals, bleach or dyes
Drugs or medications that can cause temporary hair loss (Chemotheraputic drugs, Retinoids for acne treatment, Anticoagulants or Beta-adrenergic Blockers for blood pressure, etc)**
Allergies - please describe here

**Eyelash extensions cannot be bonded to skin. If you do not have natural eyelashes we cannot apply extensions. Alopecia sufferers or people taking medications that cause hair loss are not good candidates for this service.


Is there anything else you think we should know before you have your eyelash extensions applied?
Fourth Client's Name

First Name*

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

How did you hear about us? *
Is this your first time having eyelash extensions applied?*
Are you having your eyelash extensions applied for:*
In the last 60 days, have you worn:*
Do you do any of the following to your natural eyelashes?*

These procedures cannot be done once eyelash extensions have been applied. If you wish to curl, tint or perm your natural eyelashes, please do so prior to extension application.

Do you wear contact lenses?*
Do you have or are you being treated for any eye illness or injury?*

Eye Illness or injury details:

Please list any eye drops or eye medications that you use:
Are you able to keep your eyes closed comfortably for more than 2 hours?*
Please check any of the following that may apply to you:
Lasik eye surgery
Permanent eye make-up
Blephoplasty (eye lift)
Microdermabrasion
Childbirth within the last 120 days
Major surgery within the last 120 days
Alopecia**
Hypersensitivity to cyanoacrylate, formaldehyde, any adhesives or glues
Recent high fever or illness
Regular exposure to swimming pool chemicals, bleach or dyes
Drugs or medications that can cause temporary hair loss (Chemotheraputic drugs, Retinoids for acne treatment, Anticoagulants or Beta-adrenergic Blockers for blood pressure, etc)**
Allergies - please describe here

**Eyelash extensions cannot be bonded to skin. If you do not have natural eyelashes we cannot apply extensions. Alopecia sufferers or people taking medications that cause hair loss are not good candidates for this service.


Is there anything else you think we should know before you have your eyelash extensions applied?
Fifth Client's Name

First Name*

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

How did you hear about us? *
Is this your first time having eyelash extensions applied?*
Are you having your eyelash extensions applied for:*
In the last 60 days, have you worn:*
Do you do any of the following to your natural eyelashes?*

These procedures cannot be done once eyelash extensions have been applied. If you wish to curl, tint or perm your natural eyelashes, please do so prior to extension application.

Do you wear contact lenses?*
Do you have or are you being treated for any eye illness or injury?*

Eye Illness or injury details:

Please list any eye drops or eye medications that you use:
Are you able to keep your eyes closed comfortably for more than 2 hours?*
Please check any of the following that may apply to you:
Lasik eye surgery
Permanent eye make-up
Blephoplasty (eye lift)
Microdermabrasion
Childbirth within the last 120 days
Major surgery within the last 120 days
Alopecia**
Hypersensitivity to cyanoacrylate, formaldehyde, any adhesives or glues
Recent high fever or illness
Regular exposure to swimming pool chemicals, bleach or dyes
Drugs or medications that can cause temporary hair loss (Chemotheraputic drugs, Retinoids for acne treatment, Anticoagulants or Beta-adrenergic Blockers for blood pressure, etc)**
Allergies - please describe here

**Eyelash extensions cannot be bonded to skin. If you do not have natural eyelashes we cannot apply extensions. Alopecia sufferers or people taking medications that cause hair loss are not good candidates for this service.


Is there anything else you think we should know before you have your eyelash extensions applied?
Sixth Client's Name

First Name*

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

How did you hear about us? *
Is this your first time having eyelash extensions applied?*
Are you having your eyelash extensions applied for:*
In the last 60 days, have you worn:*
Do you do any of the following to your natural eyelashes?*

These procedures cannot be done once eyelash extensions have been applied. If you wish to curl, tint or perm your natural eyelashes, please do so prior to extension application.

Do you wear contact lenses?*
Do you have or are you being treated for any eye illness or injury?*

Eye Illness or injury details:

Please list any eye drops or eye medications that you use:
Are you able to keep your eyes closed comfortably for more than 2 hours?*
Please check any of the following that may apply to you:
Lasik eye surgery
Permanent eye make-up
Blephoplasty (eye lift)
Microdermabrasion
Childbirth within the last 120 days
Major surgery within the last 120 days
Alopecia**
Hypersensitivity to cyanoacrylate, formaldehyde, any adhesives or glues
Recent high fever or illness
Regular exposure to swimming pool chemicals, bleach or dyes
Drugs or medications that can cause temporary hair loss (Chemotheraputic drugs, Retinoids for acne treatment, Anticoagulants or Beta-adrenergic Blockers for blood pressure, etc)**
Allergies - please describe here

**Eyelash extensions cannot be bonded to skin. If you do not have natural eyelashes we cannot apply extensions. Alopecia sufferers or people taking medications that cause hair loss are not good candidates for this service.


Is there anything else you think we should know before you have your eyelash extensions applied?
Seventh Client's Name

First Name*

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

How did you hear about us? *
Is this your first time having eyelash extensions applied?*
Are you having your eyelash extensions applied for:*
In the last 60 days, have you worn:*
Do you do any of the following to your natural eyelashes?*

These procedures cannot be done once eyelash extensions have been applied. If you wish to curl, tint or perm your natural eyelashes, please do so prior to extension application.

Do you wear contact lenses?*
Do you have or are you being treated for any eye illness or injury?*

Eye Illness or injury details:

Please list any eye drops or eye medications that you use:
Are you able to keep your eyes closed comfortably for more than 2 hours?*
Please check any of the following that may apply to you:
Lasik eye surgery
Permanent eye make-up
Blephoplasty (eye lift)
Microdermabrasion
Childbirth within the last 120 days
Major surgery within the last 120 days
Alopecia**
Hypersensitivity to cyanoacrylate, formaldehyde, any adhesives or glues
Recent high fever or illness
Regular exposure to swimming pool chemicals, bleach or dyes
Drugs or medications that can cause temporary hair loss (Chemotheraputic drugs, Retinoids for acne treatment, Anticoagulants or Beta-adrenergic Blockers for blood pressure, etc)**
Allergies - please describe here

**Eyelash extensions cannot be bonded to skin. If you do not have natural eyelashes we cannot apply extensions. Alopecia sufferers or people taking medications that cause hair loss are not good candidates for this service.


Is there anything else you think we should know before you have your eyelash extensions applied?
Eighth Client's Name

First Name*

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

How did you hear about us? *
Is this your first time having eyelash extensions applied?*
Are you having your eyelash extensions applied for:*
In the last 60 days, have you worn:*
Do you do any of the following to your natural eyelashes?*

These procedures cannot be done once eyelash extensions have been applied. If you wish to curl, tint or perm your natural eyelashes, please do so prior to extension application.

Do you wear contact lenses?*
Do you have or are you being treated for any eye illness or injury?*

Eye Illness or injury details:

Please list any eye drops or eye medications that you use:
Are you able to keep your eyes closed comfortably for more than 2 hours?*
Please check any of the following that may apply to you:
Lasik eye surgery
Permanent eye make-up
Blephoplasty (eye lift)
Microdermabrasion
Childbirth within the last 120 days
Major surgery within the last 120 days
Alopecia**
Hypersensitivity to cyanoacrylate, formaldehyde, any adhesives or glues
Recent high fever or illness
Regular exposure to swimming pool chemicals, bleach or dyes
Drugs or medications that can cause temporary hair loss (Chemotheraputic drugs, Retinoids for acne treatment, Anticoagulants or Beta-adrenergic Blockers for blood pressure, etc)**
Allergies - please describe here

**Eyelash extensions cannot be bonded to skin. If you do not have natural eyelashes we cannot apply extensions. Alopecia sufferers or people taking medications that cause hair loss are not good candidates for this service.


Is there anything else you think we should know before you have your eyelash extensions applied?
Ninth Client's Name

First Name*

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

How did you hear about us? *
Is this your first time having eyelash extensions applied?*
Are you having your eyelash extensions applied for:*
In the last 60 days, have you worn:*
Do you do any of the following to your natural eyelashes?*

These procedures cannot be done once eyelash extensions have been applied. If you wish to curl, tint or perm your natural eyelashes, please do so prior to extension application.

Do you wear contact lenses?*
Do you have or are you being treated for any eye illness or injury?*

Eye Illness or injury details:

Please list any eye drops or eye medications that you use:
Are you able to keep your eyes closed comfortably for more than 2 hours?*
Please check any of the following that may apply to you:
Lasik eye surgery
Permanent eye make-up
Blephoplasty (eye lift)
Microdermabrasion
Childbirth within the last 120 days
Major surgery within the last 120 days
Alopecia**
Hypersensitivity to cyanoacrylate, formaldehyde, any adhesives or glues
Recent high fever or illness
Regular exposure to swimming pool chemicals, bleach or dyes
Drugs or medications that can cause temporary hair loss (Chemotheraputic drugs, Retinoids for acne treatment, Anticoagulants or Beta-adrenergic Blockers for blood pressure, etc)**
Allergies - please describe here

**Eyelash extensions cannot be bonded to skin. If you do not have natural eyelashes we cannot apply extensions. Alopecia sufferers or people taking medications that cause hair loss are not good candidates for this service.


Is there anything else you think we should know before you have your eyelash extensions applied?
Tenth Client's Name

First Name*

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

How did you hear about us? *
Is this your first time having eyelash extensions applied?*
Are you having your eyelash extensions applied for:*
In the last 60 days, have you worn:*
Do you do any of the following to your natural eyelashes?*

These procedures cannot be done once eyelash extensions have been applied. If you wish to curl, tint or perm your natural eyelashes, please do so prior to extension application.

Do you wear contact lenses?*
Do you have or are you being treated for any eye illness or injury?*

Eye Illness or injury details:

Please list any eye drops or eye medications that you use:
Are you able to keep your eyes closed comfortably for more than 2 hours?*
Please check any of the following that may apply to you:
Lasik eye surgery
Permanent eye make-up
Blephoplasty (eye lift)
Microdermabrasion
Childbirth within the last 120 days
Major surgery within the last 120 days
Alopecia**
Hypersensitivity to cyanoacrylate, formaldehyde, any adhesives or glues
Recent high fever or illness
Regular exposure to swimming pool chemicals, bleach or dyes
Drugs or medications that can cause temporary hair loss (Chemotheraputic drugs, Retinoids for acne treatment, Anticoagulants or Beta-adrenergic Blockers for blood pressure, etc)**
Allergies - please describe here

**Eyelash extensions cannot be bonded to skin. If you do not have natural eyelashes we cannot apply extensions. Alopecia sufferers or people taking medications that cause hair loss are not good candidates for this service.


Is there anything else you think we should know before you have your eyelash extensions applied?
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.
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*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

How did you hear about us? *
Is this your first time having eyelash extensions applied?*
Are you having your eyelash extensions applied for:*
In the last 60 days, have you worn:*
Do you do any of the following to your natural eyelashes?*

These procedures cannot be done once eyelash extensions have been applied. If you wish to curl, tint or perm your natural eyelashes, please do so prior to extension application.

Do you wear contact lenses?*
Do you have or are you being treated for any eye illness or injury?*

Eye Illness or injury details:

Please list any eye drops or eye medications that you use:
Are you able to keep your eyes closed comfortably for more than 2 hours?*
Please check any of the following that may apply to you:
Lasik eye surgery
Permanent eye make-up
Blephoplasty (eye lift)
Microdermabrasion
Childbirth within the last 120 days
Major surgery within the last 120 days
Alopecia**
Hypersensitivity to cyanoacrylate, formaldehyde, any adhesives or glues
Recent high fever or illness
Regular exposure to swimming pool chemicals, bleach or dyes
Drugs or medications that can cause temporary hair loss (Chemotheraputic drugs, Retinoids for acne treatment, Anticoagulants or Beta-adrenergic Blockers for blood pressure, etc)**
Allergies - please describe here

**Eyelash extensions cannot be bonded to skin. If you do not have natural eyelashes we cannot apply extensions. Alopecia sufferers or people taking medications that cause hair loss are not good candidates for this service.


Is there anything else you think we should know before you have your eyelash extensions applied?
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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