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LASH EXTENSION INTAKE & CONSENT FORM


Waiver of Liability

I understand there are risks associated with having artificial lashes applied to and/or removed from my existing natural eyelashes and that notwithstanding the utmost of care in the application or removal of these products, there still exist risks associated with the procedure and the product itself, which includes without limitation, eye irritation, eye pain, discomfort and in rare cases blindness when improperly handles. As part of the procedure, I understand that a certain amount of eyelash adhesive material will be used to attach the lash extension to my existing eyelashes, even though the Professional will take the utmost care of to apply or remove my lash extensions properly, I understand that 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 that there are more than one technique for applying eyelash extensions to my eyelashes and I will not attribute any liability to the Professional at. Beyond Beauty by Whitney from any and all claims, actions, expense, damages and liabilities including reasonable attorney’s fees which might be asserted against them as a results of my having this procedure performed, or my purchase of these eyelash extensions or product’s.

Permission to Use Pictures

I hereby grant Beyond Beauty by Whitney LLC the full right to take, publish and reproduce photographs of me, my face, eyes and/or eyelashes 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 Beyond Beauty by Whitney. I further expressly assign any copyright in these photographs to Beyond Beauty by Whitney. I also grant my consent for Beyond Beauty by Whitney to use my images and likeness as contained in these photographs for any advertising of other purposes, along with any comments I may provide.

If appointment is canceled same day or less than 48 HOURS prior to the appointment a $75 fee will need to be paid via Credit/ Debit card, Apple Pay, Venmo, or by invoice the day of the cancellation.

December 22, 2024

 

 

First Client's Name

First Name*

Middle Name

Last Name*

Phone*
First Client's Age Acknowledgment*
First Client's Date of Birth*
I certify that I am 18 years of age or older
First Client's Information

Select YES OR NO

Is this the first time you have had lash extensions applied?*
No
Yes
Do you perm -or- tint your lashes?*
No
Yes
Do you wear eye contacts?*
No
Yes
Do you have, or are you being treated for any eye illness or injury?*
No
Yes
Do you have sensitives such as itchy eyes, dry eyes or seasonal hay fever?*
No
Yes
Are you able to keep your eyes closed and lie still for up to 2 hours or longer?*
No
Yes
Are you allergic to Latex, Acrylates, Glue, Tape or Adhesives?*
No
Yes
allergic

Additional Questions


What position do you predominately sleep in: right side, left side, on back, or stomach?

Are you having last extensions applied for a special occasion -or- daily wear?
Are you allergic to any make up products*
No
Yes

If you answered YES to any of these questions, please explain?
Select ANY that Apply to you
Lasik eye surgery
Permanent eye make up
Blepharoplasty (eye lift)
Microdermabrasion
Allergic to adhesives or synthetics
Allergic to Latex
Allergic to Glycerin
Alopecia
Thyroid disease
Hypersensitivity to Cyanoacrylate or formaldehyde or certain adhesives/glues
Recent high fever or serious illness
Iron deficiency
Taken any medications that cause temporary hair loss
Retinoids used to treat acne and skin problems ( Accutane, Retin A)
Taken anticoagulants
First Client's Signature*
Second Client's Name

First Name*

Middle Name

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

Select YES OR NO

Is this the first time you have had lash extensions applied?*
No
Yes
Do you perm -or- tint your lashes?*
No
Yes
Do you wear eye contacts?*
No
Yes
Do you have, or are you being treated for any eye illness or injury?*
No
Yes
Do you have sensitives such as itchy eyes, dry eyes or seasonal hay fever?*
No
Yes
Are you able to keep your eyes closed and lie still for up to 2 hours or longer?*
No
Yes
Are you allergic to Latex, Acrylates, Glue, Tape or Adhesives?*
No
Yes
allergic

Additional Questions


What position do you predominately sleep in: right side, left side, on back, or stomach?

Are you having last extensions applied for a special occasion -or- daily wear?
Are you allergic to any make up products*
No
Yes

If you answered YES to any of these questions, please explain?
Select ANY that Apply to you
Lasik eye surgery
Permanent eye make up
Blepharoplasty (eye lift)
Microdermabrasion
Allergic to adhesives or synthetics
Allergic to Latex
Allergic to Glycerin
Alopecia
Thyroid disease
Hypersensitivity to Cyanoacrylate or formaldehyde or certain adhesives/glues
Recent high fever or serious illness
Iron deficiency
Taken any medications that cause temporary hair loss
Retinoids used to treat acne and skin problems ( Accutane, Retin A)
Taken anticoagulants
Third Client's Name

First Name*

Middle Name

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

Select YES OR NO

Is this the first time you have had lash extensions applied?*
No
Yes
Do you perm -or- tint your lashes?*
No
Yes
Do you wear eye contacts?*
No
Yes
Do you have, or are you being treated for any eye illness or injury?*
No
Yes
Do you have sensitives such as itchy eyes, dry eyes or seasonal hay fever?*
No
Yes
Are you able to keep your eyes closed and lie still for up to 2 hours or longer?*
No
Yes
Are you allergic to Latex, Acrylates, Glue, Tape or Adhesives?*
No
Yes
allergic

Additional Questions


What position do you predominately sleep in: right side, left side, on back, or stomach?

Are you having last extensions applied for a special occasion -or- daily wear?
Are you allergic to any make up products*
No
Yes

If you answered YES to any of these questions, please explain?
Select ANY that Apply to you
Lasik eye surgery
Permanent eye make up
Blepharoplasty (eye lift)
Microdermabrasion
Allergic to adhesives or synthetics
Allergic to Latex
Allergic to Glycerin
Alopecia
Thyroid disease
Hypersensitivity to Cyanoacrylate or formaldehyde or certain adhesives/glues
Recent high fever or serious illness
Iron deficiency
Taken any medications that cause temporary hair loss
Retinoids used to treat acne and skin problems ( Accutane, Retin A)
Taken anticoagulants
Fourth Client's Name

First Name*

Middle Name

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

Select YES OR NO

Is this the first time you have had lash extensions applied?*
No
Yes
Do you perm -or- tint your lashes?*
No
Yes
Do you wear eye contacts?*
No
Yes
Do you have, or are you being treated for any eye illness or injury?*
No
Yes
Do you have sensitives such as itchy eyes, dry eyes or seasonal hay fever?*
No
Yes
Are you able to keep your eyes closed and lie still for up to 2 hours or longer?*
No
Yes
Are you allergic to Latex, Acrylates, Glue, Tape or Adhesives?*
No
Yes
allergic

Additional Questions


What position do you predominately sleep in: right side, left side, on back, or stomach?

Are you having last extensions applied for a special occasion -or- daily wear?
Are you allergic to any make up products*
No
Yes

If you answered YES to any of these questions, please explain?
Select ANY that Apply to you
Lasik eye surgery
Permanent eye make up
Blepharoplasty (eye lift)
Microdermabrasion
Allergic to adhesives or synthetics
Allergic to Latex
Allergic to Glycerin
Alopecia
Thyroid disease
Hypersensitivity to Cyanoacrylate or formaldehyde or certain adhesives/glues
Recent high fever or serious illness
Iron deficiency
Taken any medications that cause temporary hair loss
Retinoids used to treat acne and skin problems ( Accutane, Retin A)
Taken anticoagulants
Fifth Client's Name

First Name*

Middle Name

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

Select YES OR NO

Is this the first time you have had lash extensions applied?*
No
Yes
Do you perm -or- tint your lashes?*
No
Yes
Do you wear eye contacts?*
No
Yes
Do you have, or are you being treated for any eye illness or injury?*
No
Yes
Do you have sensitives such as itchy eyes, dry eyes or seasonal hay fever?*
No
Yes
Are you able to keep your eyes closed and lie still for up to 2 hours or longer?*
No
Yes
Are you allergic to Latex, Acrylates, Glue, Tape or Adhesives?*
No
Yes
allergic

Additional Questions


What position do you predominately sleep in: right side, left side, on back, or stomach?

Are you having last extensions applied for a special occasion -or- daily wear?
Are you allergic to any make up products*
No
Yes

If you answered YES to any of these questions, please explain?
Select ANY that Apply to you
Lasik eye surgery
Permanent eye make up
Blepharoplasty (eye lift)
Microdermabrasion
Allergic to adhesives or synthetics
Allergic to Latex
Allergic to Glycerin
Alopecia
Thyroid disease
Hypersensitivity to Cyanoacrylate or formaldehyde or certain adhesives/glues
Recent high fever or serious illness
Iron deficiency
Taken any medications that cause temporary hair loss
Retinoids used to treat acne and skin problems ( Accutane, Retin A)
Taken anticoagulants
Sixth Client's Name

First Name*

Middle Name

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

Select YES OR NO

Is this the first time you have had lash extensions applied?*
No
Yes
Do you perm -or- tint your lashes?*
No
Yes
Do you wear eye contacts?*
No
Yes
Do you have, or are you being treated for any eye illness or injury?*
No
Yes
Do you have sensitives such as itchy eyes, dry eyes or seasonal hay fever?*
No
Yes
Are you able to keep your eyes closed and lie still for up to 2 hours or longer?*
No
Yes
Are you allergic to Latex, Acrylates, Glue, Tape or Adhesives?*
No
Yes
allergic

Additional Questions


What position do you predominately sleep in: right side, left side, on back, or stomach?

Are you having last extensions applied for a special occasion -or- daily wear?
Are you allergic to any make up products*
No
Yes

If you answered YES to any of these questions, please explain?
Select ANY that Apply to you
Lasik eye surgery
Permanent eye make up
Blepharoplasty (eye lift)
Microdermabrasion
Allergic to adhesives or synthetics
Allergic to Latex
Allergic to Glycerin
Alopecia
Thyroid disease
Hypersensitivity to Cyanoacrylate or formaldehyde or certain adhesives/glues
Recent high fever or serious illness
Iron deficiency
Taken any medications that cause temporary hair loss
Retinoids used to treat acne and skin problems ( Accutane, Retin A)
Taken anticoagulants
Seventh Client's Name

First Name*

Middle Name

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

Select YES OR NO

Is this the first time you have had lash extensions applied?*
No
Yes
Do you perm -or- tint your lashes?*
No
Yes
Do you wear eye contacts?*
No
Yes
Do you have, or are you being treated for any eye illness or injury?*
No
Yes
Do you have sensitives such as itchy eyes, dry eyes or seasonal hay fever?*
No
Yes
Are you able to keep your eyes closed and lie still for up to 2 hours or longer?*
No
Yes
Are you allergic to Latex, Acrylates, Glue, Tape or Adhesives?*
No
Yes
allergic

Additional Questions


What position do you predominately sleep in: right side, left side, on back, or stomach?

Are you having last extensions applied for a special occasion -or- daily wear?
Are you allergic to any make up products*
No
Yes

If you answered YES to any of these questions, please explain?
Select ANY that Apply to you
Lasik eye surgery
Permanent eye make up
Blepharoplasty (eye lift)
Microdermabrasion
Allergic to adhesives or synthetics
Allergic to Latex
Allergic to Glycerin
Alopecia
Thyroid disease
Hypersensitivity to Cyanoacrylate or formaldehyde or certain adhesives/glues
Recent high fever or serious illness
Iron deficiency
Taken any medications that cause temporary hair loss
Retinoids used to treat acne and skin problems ( Accutane, Retin A)
Taken anticoagulants
Eighth Client's Name

First Name*

Middle Name

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

Select YES OR NO

Is this the first time you have had lash extensions applied?*
No
Yes
Do you perm -or- tint your lashes?*
No
Yes
Do you wear eye contacts?*
No
Yes
Do you have, or are you being treated for any eye illness or injury?*
No
Yes
Do you have sensitives such as itchy eyes, dry eyes or seasonal hay fever?*
No
Yes
Are you able to keep your eyes closed and lie still for up to 2 hours or longer?*
No
Yes
Are you allergic to Latex, Acrylates, Glue, Tape or Adhesives?*
No
Yes
allergic

Additional Questions


What position do you predominately sleep in: right side, left side, on back, or stomach?

Are you having last extensions applied for a special occasion -or- daily wear?
Are you allergic to any make up products*
No
Yes

If you answered YES to any of these questions, please explain?
Select ANY that Apply to you
Lasik eye surgery
Permanent eye make up
Blepharoplasty (eye lift)
Microdermabrasion
Allergic to adhesives or synthetics
Allergic to Latex
Allergic to Glycerin
Alopecia
Thyroid disease
Hypersensitivity to Cyanoacrylate or formaldehyde or certain adhesives/glues
Recent high fever or serious illness
Iron deficiency
Taken any medications that cause temporary hair loss
Retinoids used to treat acne and skin problems ( Accutane, Retin A)
Taken anticoagulants
Ninth Client's Name

First Name*

Middle Name

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

Select YES OR NO

Is this the first time you have had lash extensions applied?*
No
Yes
Do you perm -or- tint your lashes?*
No
Yes
Do you wear eye contacts?*
No
Yes
Do you have, or are you being treated for any eye illness or injury?*
No
Yes
Do you have sensitives such as itchy eyes, dry eyes or seasonal hay fever?*
No
Yes
Are you able to keep your eyes closed and lie still for up to 2 hours or longer?*
No
Yes
Are you allergic to Latex, Acrylates, Glue, Tape or Adhesives?*
No
Yes
allergic

Additional Questions


What position do you predominately sleep in: right side, left side, on back, or stomach?

Are you having last extensions applied for a special occasion -or- daily wear?
Are you allergic to any make up products*
No
Yes

If you answered YES to any of these questions, please explain?
Select ANY that Apply to you
Lasik eye surgery
Permanent eye make up
Blepharoplasty (eye lift)
Microdermabrasion
Allergic to adhesives or synthetics
Allergic to Latex
Allergic to Glycerin
Alopecia
Thyroid disease
Hypersensitivity to Cyanoacrylate or formaldehyde or certain adhesives/glues
Recent high fever or serious illness
Iron deficiency
Taken any medications that cause temporary hair loss
Retinoids used to treat acne and skin problems ( Accutane, Retin A)
Taken anticoagulants
Tenth Client's Name

First Name*

Middle Name

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

Select YES OR NO

Is this the first time you have had lash extensions applied?*
No
Yes
Do you perm -or- tint your lashes?*
No
Yes
Do you wear eye contacts?*
No
Yes
Do you have, or are you being treated for any eye illness or injury?*
No
Yes
Do you have sensitives such as itchy eyes, dry eyes or seasonal hay fever?*
No
Yes
Are you able to keep your eyes closed and lie still for up to 2 hours or longer?*
No
Yes
Are you allergic to Latex, Acrylates, Glue, Tape or Adhesives?*
No
Yes
allergic

Additional Questions


What position do you predominately sleep in: right side, left side, on back, or stomach?

Are you having last extensions applied for a special occasion -or- daily wear?
Are you allergic to any make up products*
No
Yes

If you answered YES to any of these questions, please explain?
Select ANY that Apply to you
Lasik eye surgery
Permanent eye make up
Blepharoplasty (eye lift)
Microdermabrasion
Allergic to adhesives or synthetics
Allergic to Latex
Allergic to Glycerin
Alopecia
Thyroid disease
Hypersensitivity to Cyanoacrylate or formaldehyde or certain adhesives/glues
Recent high fever or serious illness
Iron deficiency
Taken any medications that cause temporary hair loss
Retinoids used to treat acne and skin problems ( Accutane, Retin A)
Taken anticoagulants
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.


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*

Middle Name

Last Name*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Select YES OR NO

Is this the first time you have had lash extensions applied?*
No
Yes
Do you perm -or- tint your lashes?*
No
Yes
Do you wear eye contacts?*
No
Yes
Do you have, or are you being treated for any eye illness or injury?*
No
Yes
Do you have sensitives such as itchy eyes, dry eyes or seasonal hay fever?*
No
Yes
Are you able to keep your eyes closed and lie still for up to 2 hours or longer?*
No
Yes
Are you allergic to Latex, Acrylates, Glue, Tape or Adhesives?*
No
Yes
allergic

Additional Questions


What position do you predominately sleep in: right side, left side, on back, or stomach?

Are you having last extensions applied for a special occasion -or- daily wear?
Are you allergic to any make up products*
No
Yes

If you answered YES to any of these questions, please explain?
Select ANY that Apply to you
Lasik eye surgery
Permanent eye make up
Blepharoplasty (eye lift)
Microdermabrasion
Allergic to adhesives or synthetics
Allergic to Latex
Allergic to Glycerin
Alopecia
Thyroid disease
Hypersensitivity to Cyanoacrylate or formaldehyde or certain adhesives/glues
Recent high fever or serious illness
Iron deficiency
Taken any medications that cause temporary hair loss
Retinoids used to treat acne and skin problems ( Accutane, Retin A)
Taken anticoagulants
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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