Eyelash Extension Consent Form ContactName(Required) First Last Email(Required) Phone(Required)Phone Type(Required) Home Mobile Work Other It's OK to text me! Yes No Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code ContraindicationsI understand that this procedure has contraindications. Please indicate if you have the following:(Required) Current use of contact lenses which I may be asked to remove during the procedure Current use of anything such as oil-containing sunscreen or moisturizers around the eyes Current use of eye drops of any kind, prescription or over-the-counter Current allergies or sensitivities History of recurrent eye or tear duct infections History of dry eyes or Sjorgen’s Syndrome Recent history of Chemotherapy Other medical conditions which would prohibit or compromise placement and retention of eyelash extensions Agreement(Required) I agree to have eyelash extensions applied to my natural eyelashes and/or removed and retouched. By signing this agreement, I consent to the placement and/or removal of the eyelash extensions by my Esthetician.• I understand that compliance to post-care instructions will greatly affect my result. I acknowledge my obligation to follow the written and spoken instructions covering my pre- and post-treatment lash care regimen. • I understand that in 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 that if I experience any of these conditions with my lashes that I will contact the Esthetician that performed this procedure, and it may be beneficial to have the eyelashes removed. • I consent to photographs being taken. No photographs revealing my identity will be used without my written consent. • I understand my eyes will be closed for the duration of this service, anywhere from 60-120 minutes.I agree to the following eyelash extension follow-up and maintenance instructions (please check each one)(Required) 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 Consent(Required) I agree to the notice.My signature below constitutes acknowledgement that I have read and understand the foregoing consent form and agree to the treatment. I hereby give consent to my Esthetician to perform an eyelash extensions application. I hold harmless LaVida Massage, my Esthetician and affiliates of all circumstances that may occur during my treatment. By signing below, I acknowledge the information provided is true and correct to the best of my knowledge. I agree that I am willing to follow recommendations by my Esthetician for home care. I will be responsible for following home regimens that can minimize or eliminate possible negative reactions. If I have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult my Esthetician immediately. I HEREBY AFFIRM: I AM 18 YEARS OF AGE OR OLDER. I HAVE CAREFULLY READ THIS DOCUMENT, AND I UNDERSTAND ITS CONTENTS. I AM AWARE THIS DOCUMENT IS A RELEASE OF ALL LIABILITY AND A CONTRACT ENFORCEABLE AGAINST ME (AND MY HEIRS, NEXT OF KIN, DISTRIBUTEES, GUARDIANS, LEGAL REPRESENTATIVES, EXECUTORS, ADMINISTRATORS, SUCCESSORS AND ASSIGNS) IN A COURT OF LAW. I HAVE SIGNED THIS DOCUMENT OF MY OWN FREE WILL. By signing below, I agree I have read and agree to the legal agreements above.Signature(Required)NameThis field is for validation purposes and should be left unchanged.
