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Eyelash Extensions Consent / Liability Waiver


Thank you for choosing Luxuriant By Eugina, we look forward to a long & lengthy lash affair with you!



CONSENT FORM & RELEASE

THIS SECTION MUST BE COMPLETED IN ORDER TO PROCEED WITH THE SERVICE

I Agree
I agree to have eyelash extensions applied to my natural eyelashes and/or removed and retouched/refilled. By signing this agreement, I consent to the placement and/or removal of the eyelash extensions by the certified eyelash extension professional.

I Agree
 I understand that on rare occasions, there are risks associated with having artificial eyelashes and eyelash extensions applied to or removed from my natural eyelashes. I further understand that in rare cases as part of the procedure, eye irritation and discomfort could occur.

I Agree
 I agree that if I experience any of these conditions with my lashes that I will contact the certified eyelash extension professional that performed this procedure and it may be beneficial to have the eyelashes removed.

I Agree
I understand and agree to the after-care instructions provided by the certified eyelash extension professional for the use and care of my eyelash extensions. I realize and accept the consequences of failure to adhere to these instructions may cause the eyelash extensions to fall out and/or decrease the time the lashes will last.

I Agree
I understand and consent to have my eyes closed and covered for an approximately 60-120 minute procedure. Times may vary depending on the type and number of eyelashes applied.

I Agree
I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications. I understand that additional conditions could occur or be discovered during the procedure, which could affect my ability to tolerate the procedure.


WAIVER OF LIABILITY

THIS SECTION MUST BE COMPLETED IN ORDER TO PROCEED WITH THE SERVICE

I Agree
I understand there are risks associated with having artificial eyelashes applied to or removed from my existing eyelashes. Even with 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 lashes to my existing eyelashes. Even though the service provider may apply or remove my lashes properly, I understand adhesive material may become dislodged during or after the procedure. This may irritate my eyes or require further follow-up care, at my own expense to prevent damage to my eyes.

I Agree
I also understand there is more than one technique for applying lash extensions to my eyelashes, and I will not attribute any liability to the service provider a result of this procedure or the use and care of these lashes. I also agree to defend, indemnify and hold the service provider harmless 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. As used in this agreement, the term “service provider” includes all of their respective officers, directors, agents, employees, successors, and assigns.


INFORMEDCONSENT

THIS SECTION MUST BE COMPLETED IN ORDER TO PROCEED WITH THE SERVICE

I Agree
All the information I provided on the medical questionnaire is the truth to my best knowledge. 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 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 the service provider's instructions or these warnings.

I Agree
This agreement will remain in effect for this procedure, and all future procedures conducted by the service provider. I agree that this agreement is binding upon me, and my heirs, legal representatives, and assigns.


PHOTO & VIDEO RELEASE

I Agree
I hereby grant permission to the rights of my image, likeness, and sound of my voice as recorded on audio or video without payment or any other consideration. I understand that my image may be edited, copied, exhibited, published, or distributed and waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area.

Photographic, audio or video recordings may be used for the following purposes: • educational presentations or courses

• informational presentations

• online educational courses

By signing this release, I understand this permission signifies that photographic or video recordings of me may be electronically displayed via the Internet or in the public educational setting.

I will be consulted about the use of the photographs or video recording for any purpose other than those

listed above.

There is no time limit on the validity of this release, nor is there any geographic limitation on where these materials may be distributed.

This release applies to photographic, audio, or video recordings collected as part of the sessions listed on this document only.




By signing this form, I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for educational purposes.



Client Questionnaire
1. Is this the first time you've had eyelash extensions?*
No
Yes
Do you have any damage/breakage to your natural lashes?*
No
Yes
Have you recently had a lash tint or lash perm?*
No
Yes
Do you currently wear glasses or contacts?*
No
Yes
Do you have or are you currently being treated for any eye conditions?*
No
Yes
Are you allergic to any acrylic or latex?*
No
Yes
Have you ever had or do you currently have any of the following conditions?
Alopecia/ Blepharitis
Diabetes
Hormonal Imbalances / Migraines
Strokes
Current Eye Irritation / Eye Sensitivity
Asthma
Dry Eyes
Cancer And/Or Chemo Treatments
Rosacea
Possible Pregnancy
Back Pain
Pink Eye
Light Sensitivity
Recent Eye Surgery
QUESTIONS RELEVANT TO YOUR LASH HAIR GROWTH, AND OVERALL HAIR HEALTH:
Are you pregnant or trying to become pregnant?*
No
Yes
Are you breast-feeding, or on a restricted to diet to breast-feed?*
No
Yes
Are you using oral and/or hormone-based contraceptives?*
No
Yes
Do you use Retin-A or Accutane? *
No
Yes
Do you go tanning?*
No
Yes
Do you receive any facial treatments, especially steaming facials?*
No
Yes
Do you use Latisse or any lash growth serums?*
No
Yes
Do work outside, or in any conditions of extreme heat?*
No
Yes
First CLIENT INFORMATION Name

First Name*

Middle Name

Last Name*

Phone*
First CLIENT INFORMATION Date of Birth*
First CLIENT INFORMATION Signature*
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*
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 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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