Lash Extensions - Client Consent & Waiver Form

*Please be sure to complete this form, prior to your arrival. It is a required form, and must be completed before any lash service begins. We do have paper copies available, if you are unable complete this form electronically. Thank you!
Today's Date*

MonthDayYear
Date
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Birth Date*

MonthDayYear
Date
How did you hear about us?

GoogleTwitterFacebookInstagramYelpFriend/FamilyOther
Have you ever had eyelash extensions applied before?*

YesNo
When?
Where?
If Yes: did you have any adverse reactions or negative experiences during or after the procedure? If Yes: What happened?
Are you having them applied for daily wear or special occasion? *

Daily WearSpecial Occassion
Do you wear contacts? (Please understand we may ask you to remove them before the application) *

YesNo
Have you been treated for any eye illness or injury?*

YesNo
Please list any eye drops or eye medications you are using:
Additional Comments:
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 the licensed and/or certified eyelash extension professional.*

I agree
I understand that in rare occasions there are risks associated with having artificial eyelashes, lash adhesives, lash chemicals, solutions, glues, glue removers, 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 seek medical attention immediately (at no expense to Exclusive Lash Bar & Nail Candy, and/or its licensed professionals), and then contact the eyelash extension professional that performed my lash service to have the eyelashes removed. *

I agree and I understand.
I understand and agree to the after-care instructions provided by the 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 and I understand.
I understand and consent to having my eyes closed and covered for the duration of approximately 30-190 minute procedure. Times may vary depending on the type and number of eyelashes applied, technique, and repair work if coming from another salon. *

I agree and I consent.
I understand these medical conditions which would prohibit or compromise placement and retention of eyelash extensions, including but not limited to:
Skin Condition around eye area (such as Eczema, Dermatitis, Psoriasis)
Any eye surgery (within the last 6 months)
Conjunctivitis
Recent eye infection
Cataracts
Diabetic Retinopathy
Alopecia
Trichotillomania
Hordeolum/ Styes
Hay Fever
Watery Eye
Blepharitis
Alopecia
Corneal Disease
Dry Eye Syndrome
Glaucoma
Permanent Makeup Eyeliner done within the past 8 weeks
I understand.
I am informing the eyelash extension professional of the following conditions by marking with a check: *

Current use of contact lenses which I may be asked to remove during the procedureCurrent use of anything such as oil-containing sunscreen or moisturizers around the eyesCurrent use of eye drops of any kind, prescription or over-the-counterCurrent allergies or sensitivitiesHistory of recurrent eye or tear duct infections History of dry eyes or Sjorgen’s SyndromeRecent history of ChemotherapyOther medical conditions which would prohibit or compromise placement and retention of eyelash extensionsLASIK (done in the last 6 months)Permanent Makeup Eyeliner done within the past 8 weeksAny eye surgery on or near the eye areaNone of these apply to me
I agree to the following eyelash extension After-Care Instructions *

No waterproof or oil-based mascara, including on bottom lashesNo oil based products around the eye areaNo water can come in contact with the eye area for 24 hours after the application or as instructed by my eyelash extension professional.No tinting or perming of eyelash extensionsNo pulling, rubbing, picking, or sleeping on eyelash extensionsShould any kind of eye drops be necessary, extra care should be taken to prevent moisture from coming into contact with the eyelash extensions
Exclusive Lash Bar & Nail Candy may use your before & after photos on our website or social media. Please indicate if you prefer to not allow us to use photos of you or your lashes. *

Yes, you may use my photos.No, please do not use my photos.
This agreement will remain in effect for this procedure and all future follow-ups conducted by the 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.*

I agree and I understand.
Signature*
Should be Empty:

*Please be sure to complete this form, prior to your arrival. It is a required form, and must be completed before any lash service begins. We do have paper copies available, if you are unable complete this form electronically. Thank you!