Lash extensions forms New Client Intake Form New Client Intake Form Name * First Name Last Name Date of Birth * MM DD YYYY Phone * (###) ### #### Email * How did you hear about us? * Instagram Referral Who referred you? Eyelash Extension History Have you had eyelash extensions applied before? * Yes No Do you use any of the following products on your eyelashes? * Mascara Lash Serum None Do you do any of the following to your lashes? * Curl Lash Lift Tint None Do you wear eye glasses? * Yes No Do you wear contact lenses? * Yes No Do you have frequent eye irritation itching, or watery eyes? * Yes No Do you have, or are you being treated for any kind of eye injury? * Yes No If yes, please explain: Are you allergic to any of the following? * Acrylic Latex Other None If other, please state what you are allergic to: Do you have any of the following conditions? (please check all that apply) Alopecia Conjunctivitis Eczema Thyroid Disease Cancer Diabetes Glaucoma Recent Eye Infection Cataract Dry Eyes Psoriasis Around the Eyes Sensitive Eyes Photograph and Video Release Agreement I grant and authorize Zabé Beauty the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures, video, and/or audio is taken of me to be used in and/or for any lawful promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, press kits, websites, social networking sites, and other print or digital communications without payment or any other consideration. This authorization extends to all languages, media, formats, and markets now known or later discovered. I waive the right to inspect or approve the finished product wherein my likeness appears, including a written or electronic copy. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I hereby hold harmless and release Zabé Beauty from all liability, petitions, and causes of action which I, my heirs, representatives, executors, or any other persons may make while acting on my behalf or on behalf of my estate. Please read the statement above and initial to agree. * By signing below, I agree to the following: I have completed this form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liability toward my technician and the salon for any injury or damages incurred due to any misrepresentation of my health. Sign Name * Date MM DD YYYY Thank you! Eyelash Extension Consent Form Eyelash Extension Consent Form Name * First Name Last Name Date of Birth * MM DD YYYY Phone (###) ### #### Email * Although every precaution will be taken to ensure my safety and wellbeing before, during and after my lash extension application, I am aware of the following information and possible risks. By initialing below you agree to the following: I agree to have eyelash extensions applied to my natural eyelashes and/or removed and retouched. I consent to the placement and/or removal of the eyelash extensions by the certified eyelash extension professional. * I understand that a full set of lash extensions can make the appearance of my own lashes about 30-50% thicker, and make my lashes appear 20-50% longer. * I understand that lash extension services have some inherent risk of irritation to the orbital eye area, including the eye itself, and could result in stinging and burning, blurry vision and potential blindness should the adhesive enter the eye or should an allergic reaction occur. * I understand that some irritation, itching, or burning may occur on the skin if the bonding agent comes into contact with it. * I understand that if the bonding agent comes into contact with my eye, my eye will be flushed with water and I will be assisted in seeking medical attention immediately. * I understand that this is a semi-permanent procedure, as my natural lashes will continue to grow and fall out normally, making touch-up or “fill” appointments necessary to maintain the original look achieved by replacing the lashes that have fallen out. * I understand that while every attempt will be made to provide me with the length and fullness I have chosen, my final result may not be what I initially envisioned. * I understand that it is imperative that I disclose all of the information requested on the Client Intake Form. * 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. * I consent to “before and after” photographs for the purpose of documentation, potential advertising, and promotional purposes. * I agree that if I experience any ill effects with my lashes that I will contact the certified eyelash extension professional that performed this procedure. * I understand that if I experience ill effects it may be beneficial to have the eyelashes removed. * 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 and I understand that it may cause the eyelash extensions to fall out and/or decrease the time the lashes will last. * I understand and consent to have my eyes closed and covered for the duration of an approximately 60-120 minute procedure. I understand that times may vary depending on the type and number of eyelashes applied. * I am informing the certified eyelash extension professional of the following conditions that apply to me (check all that apply): I currently use contact lenses (which I may be asked to remove during the procedure) I currently use products such as oil-containing sunscreen or moisturizers around my eyes I currently use eye drops I have allergies or sensitivities I have a history of recurrent eye or tear duct infections I have a history of dry eyes or Sjogren’s Syndrome I have a recent history of Chemotherapy I have other medical conditions which would prohibit or compromise placement and retention of eyelash extensions I agree to the following eyelash extension follow-up and maintenance instructions: * Check to agree 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 This agreement will remain in effect for this procedure and all future follow-ups conducted by the certified eyelash extension professional. I 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. Sign Name * Date MM DD YYYY Thank you! Parental Eyelash Extension Consent Form Parental Eyelash Extension Consent Form Name * First Name Last Name Date of Birth * MM DD YYYY Phone (###) ### #### Email * Although every precaution will be taken to ensure my safety and wellbeing before, during and after my lash extension application, I am aware of the following information and possible risks. By initialing below you agree to the following: agree to have eyelash extensions applied to my natural eyelashes and/or removed and retouched. I consent to the placement and/or removal of the eyelash extensions by the certified eyelash extension professional. * I understand that a full set of lash extensions can make the appearance of my own lashes about 30-50% thicker, and make my lashes appear 20-50% longer. * I understand that lash extension services have some inherent risk of irritation to the orbital eye area, including the eye itself, and could result in stinging and burning, blurry vision and potential blindness should the adhesive enter the eye or should an allergic reaction occur. * I understand that some irritation, itching, or burning may occur on the skin if the bonding agent comes into contact with it. * I understand that if the bonding agent comes into contact with my eye, my eye will be flushed with water and I will be assisted in seeking medical attention immediately. * I understand that this is a semi-permanent procedure, as my natural lashes will continue to grow and fall out normally, making touch-up or “fill” appointments necessary to maintain the original look achieved by replacing the lashes that have fallen out. * I understand that while every attempt will be made to provide me with the length and fullness I have chosen, my final result may not be what I initially envisioned. * I understand that it is imperative that I disclose all of the information requested on the Client Intake Form. * 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. * I consent to “before and after” photographs for the purpose of documentation, potential advertising, and promotional purposes. * I agree that if I experience any ill effects with my lashes that I will contact the certified eyelash extension professional that performed this procedure. * I understand that if I experience ill effects it may be beneficial to have the eyelashes removed. * 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 and I understand that it may cause the eyelash extensions to fall out and/or decrease the time the lashes will last. * I understand and consent to have my eyes closed and covered for the duration of an approximately 60-120 minute procedure. I understand that times may vary depending on the type and number of eyelashes applied. * I am informing the certified eyelash extension professional of the following conditions that apply to me (check all that apply): I currently use contact lenses (which I may be asked to remove during the procedure) I currently use products such as oil-containing sunscreen or moisturizers around my eyes I currently use eye drops I have allergies or sensitivities I have a history of recurrent eye or tear duct infections I have a history of dry eyes or Sjogren’s Syndrome I have a recent history of Chemotherapy I have other medical conditions which would prohibit or compromise placement and retention of eyelash extensions I agree to the following eyelash extension follow-up and maintenance instructions: * Check to agree 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 This agreement will remain in effect for this procedure and all future follow-ups conducted by the certified eyelash extension professional. I 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, or if I am under 18 years of age, I have had my parent or legal guardian consent to this agreement, and his or her relationship with me is as follows: * Sign your name if your 18 and older OR have your parent or legal guardian sign their name if you are under 18 years of age. Sign Client Name * Sign Parent/Guardian Name Date MM DD YYYY Thank you!
