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Lash-Covid

COVID-19 Liability Release Waiver

Due to the outbreak of the novel Coronavirus (COVID-19), Lash and Nail Spa is doing everything we can to protect you, our clients, our community and our staff. To this extent, Lash and Nail Spa will be following the Center of Disease-Control (CDC) and the Florida Department of Health guidance with regard to social distancing practices and sanitation. We ask that our clients disclose their health history and continue to implement these sanitation and disinfection procedures. 

Symptoms of COVID-19 include:

  • Fever
  • Fatique
  • Dry Cough
  • Difficulty Breathing

I agree to the following: *

I, nor members of my household, have not experienced any of the symptoms listed above within the last 14 days.I, nor members of my household, have not travelled internationally in the last 30 days.I, nor members of my household, have not traveled to a highly impacted area within the United States of America is the last 30 days.I, nor members of my household, do not believe that we have been exposed to someone with a suspected and/or confirmed case of the Coronavirus (COVID-19).I, nor members of my household, have not been diagnosed with the Coronavirus (COVID-19) within the last 30 days.Lash and Nail Spa cannot be held liable from any exposure to the Coronavirus (COVID-19) caused by misinformation on this form or the health history provided by each client. If I take any steps to make a claim for damages against Jolene Nails, its agents, employees or any other released parties, I shall be obligated to pay all attorney’s fees and costs incurred as a result of such claim

Lash and Nail Spa is following these enhanced procedures to prevent the spread of the Coronavirus (COVID-19)

  • All clients must wear a mask/mouth/nose coverings during the duration of the service or service will be denied
  • Additional time will be scheduled in between client appointments to limit client contact.  
  • Each client is required to wash their hands upon arrival and before departure.
  • All nail technicians will thoroughly clean customers’ hands before service
  • All equipment used during treatment will be cleaned, sterilized, and disinfected
  • All surfaces will be thoroughly cleaned with hospital grade disinfectant before and after each client, according to the manufacturer’s directions. 

By signing below, I hereby release and agree to hold Lash and Nail Spa harmless from and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses, and compensation for damages or loss to myself and/or property that may be caused by any act, or failure to act of the salon, or that may otherwise arise in any way in connection with any services received from Lash and Nail Spa. 

Lash and Nail Spa agrees to abide by CDC standard relaged to COVID-19.

I agree to release Lash and Nail Spa from any and all liability for the unintentional exposure or harm due to the Coronavirus (COVID-19)

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Eyelash Extension Concent Form

I have agreed to have Lash and Nail Spa apply and/or removed eyelash extensions. 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.

1. 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 exist 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 Lash and Nail Spa to my existing eyelashes. Even though the Professional may apply or remove my Lash and Nail Spa properly, I understand adhesive material may become dislodgedduring 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 alsounderstand there is more than one technique for applying Lash and Nail Spa to my eyelashes, and I will not attribute any liability to Professional or Lash and Nail Spa as a result of this procedure or the use and care of these lashes. I also agree to defend, indemnify and hold harmless Professional and Lash and Nail Spa from any and all claims, actions, expenses, damages and liabilities, including reasonable attorneys’ fees which might be asserted against them as a result of my having this procedure performed, or my purchase of these Lash and Nail Spa products. As used in this agreement, the terms “Professional” and “Lash and Nail Spa” include all of their respective officers, directors, agents, employees, successors and assigns.

2. Permission to Use Pictures. 
I hereby grant to Professional and Lash and Nail Spa the full right to take, publish and reproduce photographs ofme, my face, my eyes and/or eyelashes, both before and after this procedure, for any advertising, education, or other purposes whatsoever, includingthe right to retouch these photographs as deemed necessary by Professional or Lash and Nail Spa. I further expressly assign any copyright in thesephotographs to Lash and Nail Spa. I also grant my consent for Professional and Lash and Nail Spa to use my image and likeness as contained in these photographs for any advertising or other purposes, along with any comments I may provide.

 

3. No Known Medical Conditions / Informed Consent. 
I have read and completed the Lash and Nail Spa Client 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 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, cyanoacrolate 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 2 hours or longer with my eyes shut. I further state that I have no known medical condition that might be aggrevated by the procedure or any medical condition that would prevent me from complying with or heeding to the professional’s or Lash and Nail Spa instructions or these warnings.If any action is brought to enforce the terms of this Agreement, the prevailing party shall be entitled to its costs and reasonable attorneys’ fees.Any claims arising out of this agreement will be resolved through binding arbitration using the rules of the American Arbitration Association.This agreement will remain in effect for this procedure, and all future procedures conducted by Professional or any other professional conducting
business at the salon/spa establishment listed above.

This agreement will remain in effect for this procedure and all future follow-ups conducted by the certified eyelash extension professional. I read English and understand that this consent agreement is legal and binding. I have read and fully understand all information in this agreement. I am over 18 years of age and consent to the agreement and to the eyelash extension application procedure.

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information
Is This your first time having lash extensions applied?*
No
Yes
Do you have , or being treated for any eye illness or injury?*
No
Yes
Please check off any of the following that might apply to you:
Lasik Eye Surgery
Permanent eye make-up
Blephroplasty (eye lift)
Microdermabrasion
Allergies to adhesives or synthetics
Child birth/Major surgery within last 120 days
Alopecia
Thyroid diseases
Allergic to Glycerin
Hypersensitivity to cyanoacrylate or formaldehyde or certain adhesives/glues
Recent high fever or severe illness
Iron Deficiency
Hormonal imbalance or extreme stress
in swimming pools, and to bleach, dye and perm hair
Eating Disorders
Drugs that can cause temporary hair loss:
Chemotherapeutic agents used in cancer treatment
Retinoids used to treat acne and skin problems (such as Accutane or Retin A)
Anticoagulants
Beta-adrenergic blockers used to control blood pressure
Oral contraceptives
I agree to the following after care procedures *
For the first two days after application I understand it is best to avoid swimming, saunas or steam rooms.
No waterproof mascara
No oil based products around the eye area
No water can come in contact with the eye area for 24 hours after the application
No tinting or perming of eyelash extensions
No pulling or rubbing of the eyelash extensions
Should any kind of eye drops be necessary extra care should be taken to prevent moisture from coming into contact with the eyelash extensions
If follow up instruction are not followed Lash and Nail Spa is not liable
I should not attempt to remove my lash extension on my own
If I experience any irritation or itching , please contact Lash and Nail Spa immediately
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Is This your first time having lash extensions applied?*
No
Yes
Do you have , or being treated for any eye illness or injury?*
No
Yes
Please check off any of the following that might apply to you:
Lasik Eye Surgery
Permanent eye make-up
Blephroplasty (eye lift)
Microdermabrasion
Allergies to adhesives or synthetics
Child birth/Major surgery within last 120 days
Alopecia
Thyroid diseases
Allergic to Glycerin
Hypersensitivity to cyanoacrylate or formaldehyde or certain adhesives/glues
Recent high fever or severe illness
Iron Deficiency
Hormonal imbalance or extreme stress
in swimming pools, and to bleach, dye and perm hair
Eating Disorders
Drugs that can cause temporary hair loss:
Chemotherapeutic agents used in cancer treatment
Retinoids used to treat acne and skin problems (such as Accutane or Retin A)
Anticoagulants
Beta-adrenergic blockers used to control blood pressure
Oral contraceptives
I agree to the following after care procedures *
For the first two days after application I understand it is best to avoid swimming, saunas or steam rooms.
No waterproof mascara
No oil based products around the eye area
No water can come in contact with the eye area for 24 hours after the application
No tinting or perming of eyelash extensions
No pulling or rubbing of the eyelash extensions
Should any kind of eye drops be necessary extra care should be taken to prevent moisture from coming into contact with the eyelash extensions
If follow up instruction are not followed Lash and Nail Spa is not liable
I should not attempt to remove my lash extension on my own
If I experience any irritation or itching , please contact Lash and Nail Spa immediately
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Is This your first time having lash extensions applied?*
No
Yes
Do you have , or being treated for any eye illness or injury?*
No
Yes
Please check off any of the following that might apply to you:
Lasik Eye Surgery
Permanent eye make-up
Blephroplasty (eye lift)
Microdermabrasion
Allergies to adhesives or synthetics
Child birth/Major surgery within last 120 days
Alopecia
Thyroid diseases
Allergic to Glycerin
Hypersensitivity to cyanoacrylate or formaldehyde or certain adhesives/glues
Recent high fever or severe illness
Iron Deficiency
Hormonal imbalance or extreme stress
in swimming pools, and to bleach, dye and perm hair
Eating Disorders
Drugs that can cause temporary hair loss:
Chemotherapeutic agents used in cancer treatment
Retinoids used to treat acne and skin problems (such as Accutane or Retin A)
Anticoagulants
Beta-adrenergic blockers used to control blood pressure
Oral contraceptives
I agree to the following after care procedures *
For the first two days after application I understand it is best to avoid swimming, saunas or steam rooms.
No waterproof mascara
No oil based products around the eye area
No water can come in contact with the eye area for 24 hours after the application
No tinting or perming of eyelash extensions
No pulling or rubbing of the eyelash extensions
Should any kind of eye drops be necessary extra care should be taken to prevent moisture from coming into contact with the eyelash extensions
If follow up instruction are not followed Lash and Nail Spa is not liable
I should not attempt to remove my lash extension on my own
If I experience any irritation or itching , please contact Lash and Nail Spa immediately
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Is This your first time having lash extensions applied?*
No
Yes
Do you have , or being treated for any eye illness or injury?*
No
Yes
Please check off any of the following that might apply to you:
Lasik Eye Surgery
Permanent eye make-up
Blephroplasty (eye lift)
Microdermabrasion
Allergies to adhesives or synthetics
Child birth/Major surgery within last 120 days
Alopecia
Thyroid diseases
Allergic to Glycerin
Hypersensitivity to cyanoacrylate or formaldehyde or certain adhesives/glues
Recent high fever or severe illness
Iron Deficiency
Hormonal imbalance or extreme stress
in swimming pools, and to bleach, dye and perm hair
Eating Disorders
Drugs that can cause temporary hair loss:
Chemotherapeutic agents used in cancer treatment
Retinoids used to treat acne and skin problems (such as Accutane or Retin A)
Anticoagulants
Beta-adrenergic blockers used to control blood pressure
Oral contraceptives
I agree to the following after care procedures *
For the first two days after application I understand it is best to avoid swimming, saunas or steam rooms.
No waterproof mascara
No oil based products around the eye area
No water can come in contact with the eye area for 24 hours after the application
No tinting or perming of eyelash extensions
No pulling or rubbing of the eyelash extensions
Should any kind of eye drops be necessary extra care should be taken to prevent moisture from coming into contact with the eyelash extensions
If follow up instruction are not followed Lash and Nail Spa is not liable
I should not attempt to remove my lash extension on my own
If I experience any irritation or itching , please contact Lash and Nail Spa immediately
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Is This your first time having lash extensions applied?*
No
Yes
Do you have , or being treated for any eye illness or injury?*
No
Yes
Please check off any of the following that might apply to you:
Lasik Eye Surgery
Permanent eye make-up
Blephroplasty (eye lift)
Microdermabrasion
Allergies to adhesives or synthetics
Child birth/Major surgery within last 120 days
Alopecia
Thyroid diseases
Allergic to Glycerin
Hypersensitivity to cyanoacrylate or formaldehyde or certain adhesives/glues
Recent high fever or severe illness
Iron Deficiency
Hormonal imbalance or extreme stress
in swimming pools, and to bleach, dye and perm hair
Eating Disorders
Drugs that can cause temporary hair loss:
Chemotherapeutic agents used in cancer treatment
Retinoids used to treat acne and skin problems (such as Accutane or Retin A)
Anticoagulants
Beta-adrenergic blockers used to control blood pressure
Oral contraceptives
I agree to the following after care procedures *
For the first two days after application I understand it is best to avoid swimming, saunas or steam rooms.
No waterproof mascara
No oil based products around the eye area
No water can come in contact with the eye area for 24 hours after the application
No tinting or perming of eyelash extensions
No pulling or rubbing of the eyelash extensions
Should any kind of eye drops be necessary extra care should be taken to prevent moisture from coming into contact with the eyelash extensions
If follow up instruction are not followed Lash and Nail Spa is not liable
I should not attempt to remove my lash extension on my own
If I experience any irritation or itching , please contact Lash and Nail Spa immediately
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Is This your first time having lash extensions applied?*
No
Yes
Do you have , or being treated for any eye illness or injury?*
No
Yes
Please check off any of the following that might apply to you:
Lasik Eye Surgery
Permanent eye make-up
Blephroplasty (eye lift)
Microdermabrasion
Allergies to adhesives or synthetics
Child birth/Major surgery within last 120 days
Alopecia
Thyroid diseases
Allergic to Glycerin
Hypersensitivity to cyanoacrylate or formaldehyde or certain adhesives/glues
Recent high fever or severe illness
Iron Deficiency
Hormonal imbalance or extreme stress
in swimming pools, and to bleach, dye and perm hair
Eating Disorders
Drugs that can cause temporary hair loss:
Chemotherapeutic agents used in cancer treatment
Retinoids used to treat acne and skin problems (such as Accutane or Retin A)
Anticoagulants
Beta-adrenergic blockers used to control blood pressure
Oral contraceptives
I agree to the following after care procedures *
For the first two days after application I understand it is best to avoid swimming, saunas or steam rooms.
No waterproof mascara
No oil based products around the eye area
No water can come in contact with the eye area for 24 hours after the application
No tinting or perming of eyelash extensions
No pulling or rubbing of the eyelash extensions
Should any kind of eye drops be necessary extra care should be taken to prevent moisture from coming into contact with the eyelash extensions
If follow up instruction are not followed Lash and Nail Spa is not liable
I should not attempt to remove my lash extension on my own
If I experience any irritation or itching , please contact Lash and Nail Spa immediately
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Is This your first time having lash extensions applied?*
No
Yes
Do you have , or being treated for any eye illness or injury?*
No
Yes
Please check off any of the following that might apply to you:
Lasik Eye Surgery
Permanent eye make-up
Blephroplasty (eye lift)
Microdermabrasion
Allergies to adhesives or synthetics
Child birth/Major surgery within last 120 days
Alopecia
Thyroid diseases
Allergic to Glycerin
Hypersensitivity to cyanoacrylate or formaldehyde or certain adhesives/glues
Recent high fever or severe illness
Iron Deficiency
Hormonal imbalance or extreme stress
in swimming pools, and to bleach, dye and perm hair
Eating Disorders
Drugs that can cause temporary hair loss:
Chemotherapeutic agents used in cancer treatment
Retinoids used to treat acne and skin problems (such as Accutane or Retin A)
Anticoagulants
Beta-adrenergic blockers used to control blood pressure
Oral contraceptives
I agree to the following after care procedures *
For the first two days after application I understand it is best to avoid swimming, saunas or steam rooms.
No waterproof mascara
No oil based products around the eye area
No water can come in contact with the eye area for 24 hours after the application
No tinting or perming of eyelash extensions
No pulling or rubbing of the eyelash extensions
Should any kind of eye drops be necessary extra care should be taken to prevent moisture from coming into contact with the eyelash extensions
If follow up instruction are not followed Lash and Nail Spa is not liable
I should not attempt to remove my lash extension on my own
If I experience any irritation or itching , please contact Lash and Nail Spa immediately
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Is This your first time having lash extensions applied?*
No
Yes
Do you have , or being treated for any eye illness or injury?*
No
Yes
Please check off any of the following that might apply to you:
Lasik Eye Surgery
Permanent eye make-up
Blephroplasty (eye lift)
Microdermabrasion
Allergies to adhesives or synthetics
Child birth/Major surgery within last 120 days
Alopecia
Thyroid diseases
Allergic to Glycerin
Hypersensitivity to cyanoacrylate or formaldehyde or certain adhesives/glues
Recent high fever or severe illness
Iron Deficiency
Hormonal imbalance or extreme stress
in swimming pools, and to bleach, dye and perm hair
Eating Disorders
Drugs that can cause temporary hair loss:
Chemotherapeutic agents used in cancer treatment
Retinoids used to treat acne and skin problems (such as Accutane or Retin A)
Anticoagulants
Beta-adrenergic blockers used to control blood pressure
Oral contraceptives
I agree to the following after care procedures *
For the first two days after application I understand it is best to avoid swimming, saunas or steam rooms.
No waterproof mascara
No oil based products around the eye area
No water can come in contact with the eye area for 24 hours after the application
No tinting or perming of eyelash extensions
No pulling or rubbing of the eyelash extensions
Should any kind of eye drops be necessary extra care should be taken to prevent moisture from coming into contact with the eyelash extensions
If follow up instruction are not followed Lash and Nail Spa is not liable
I should not attempt to remove my lash extension on my own
If I experience any irritation or itching , please contact Lash and Nail Spa immediately
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Is This your first time having lash extensions applied?*
No
Yes
Do you have , or being treated for any eye illness or injury?*
No
Yes
Please check off any of the following that might apply to you:
Lasik Eye Surgery
Permanent eye make-up
Blephroplasty (eye lift)
Microdermabrasion
Allergies to adhesives or synthetics
Child birth/Major surgery within last 120 days
Alopecia
Thyroid diseases
Allergic to Glycerin
Hypersensitivity to cyanoacrylate or formaldehyde or certain adhesives/glues
Recent high fever or severe illness
Iron Deficiency
Hormonal imbalance or extreme stress
in swimming pools, and to bleach, dye and perm hair
Eating Disorders
Drugs that can cause temporary hair loss:
Chemotherapeutic agents used in cancer treatment
Retinoids used to treat acne and skin problems (such as Accutane or Retin A)
Anticoagulants
Beta-adrenergic blockers used to control blood pressure
Oral contraceptives
I agree to the following after care procedures *
For the first two days after application I understand it is best to avoid swimming, saunas or steam rooms.
No waterproof mascara
No oil based products around the eye area
No water can come in contact with the eye area for 24 hours after the application
No tinting or perming of eyelash extensions
No pulling or rubbing of the eyelash extensions
Should any kind of eye drops be necessary extra care should be taken to prevent moisture from coming into contact with the eyelash extensions
If follow up instruction are not followed Lash and Nail Spa is not liable
I should not attempt to remove my lash extension on my own
If I experience any irritation or itching , please contact Lash and Nail Spa immediately
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Is This your first time having lash extensions applied?*
No
Yes
Do you have , or being treated for any eye illness or injury?*
No
Yes
Please check off any of the following that might apply to you:
Lasik Eye Surgery
Permanent eye make-up
Blephroplasty (eye lift)
Microdermabrasion
Allergies to adhesives or synthetics
Child birth/Major surgery within last 120 days
Alopecia
Thyroid diseases
Allergic to Glycerin
Hypersensitivity to cyanoacrylate or formaldehyde or certain adhesives/glues
Recent high fever or severe illness
Iron Deficiency
Hormonal imbalance or extreme stress
in swimming pools, and to bleach, dye and perm hair
Eating Disorders
Drugs that can cause temporary hair loss:
Chemotherapeutic agents used in cancer treatment
Retinoids used to treat acne and skin problems (such as Accutane or Retin A)
Anticoagulants
Beta-adrenergic blockers used to control blood pressure
Oral contraceptives
I agree to the following after care procedures *
For the first two days after application I understand it is best to avoid swimming, saunas or steam rooms.
No waterproof mascara
No oil based products around the eye area
No water can come in contact with the eye area for 24 hours after the application
No tinting or perming of eyelash extensions
No pulling or rubbing of the eyelash extensions
Should any kind of eye drops be necessary extra care should be taken to prevent moisture from coming into contact with the eyelash extensions
If follow up instruction are not followed Lash and Nail Spa is not liable
I should not attempt to remove my lash extension on my own
If I experience any irritation or itching , please contact Lash and Nail Spa immediately
Parent or Guardian's Email Address

Email
Check to receive information, news, and discounts by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
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*
I certify that I am 18 years of age or older
Parent or Guardian's Information
Is This your first time having lash extensions applied?*
No
Yes
Do you have , or being treated for any eye illness or injury?*
No
Yes
Please check off any of the following that might apply to you:
Lasik Eye Surgery
Permanent eye make-up
Blephroplasty (eye lift)
Microdermabrasion
Allergies to adhesives or synthetics
Child birth/Major surgery within last 120 days
Alopecia
Thyroid diseases
Allergic to Glycerin
Hypersensitivity to cyanoacrylate or formaldehyde or certain adhesives/glues
Recent high fever or severe illness
Iron Deficiency
Hormonal imbalance or extreme stress
in swimming pools, and to bleach, dye and perm hair
Eating Disorders
Drugs that can cause temporary hair loss:
Chemotherapeutic agents used in cancer treatment
Retinoids used to treat acne and skin problems (such as Accutane or Retin A)
Anticoagulants
Beta-adrenergic blockers used to control blood pressure
Oral contraceptives
I agree to the following after care procedures *
For the first two days after application I understand it is best to avoid swimming, saunas or steam rooms.
No waterproof mascara
No oil based products around the eye area
No water can come in contact with the eye area for 24 hours after the application
No tinting or perming of eyelash extensions
No pulling or rubbing of the eyelash extensions
Should any kind of eye drops be necessary extra care should be taken to prevent moisture from coming into contact with the eyelash extensions
If follow up instruction are not followed Lash and Nail Spa is not liable
I should not attempt to remove my lash extension on my own
If I experience any irritation or itching , please contact Lash and Nail Spa immediately
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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