Would you like to sign up for specials and promotions?

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No

Is this the first time you have had lash extensions applied? *

Yes

No

Do you curl / perm / tint your lashes?

curl

perm

tint

Are you having lash extensions applied for:

A special occasion

Daily wear

Do you wear contacts? *

Yes

No

Do you habitually rub, pull or pick your lashes for any reason? *

Yes

No

Do you have or are you being treated for any eye illness or injury? *

Yes

No

Which side do you predominately sleep on? *

Left

Right

Back

Are you able to keep your eyes closed and lie still for up to 2 hrs or longer?

Yes

No

Please check any of the following that might apply to you:

Lasik Eye Surgery

Permanent eye makeup

Blephroplasty (eye lift)

Microdermabrasion

Allergies to adhesives or synthetics

Child birth within the last 120 days

Alopecia

Thyroid diseases

Allergic to Glycerin

Hypersensitivity to cyanoacrylate or certain adhesives/glues

Recent fever or severe illness

Iron Deficiency

Hormonal imbalance or extreme stress

Exposure to chemicals found in swimming pools, bleach, dye and perm solution

Major surgery within the last 120 days

Eating disorders

Drugs that can cause temporary hair loss

Chemotherapeutic agents used in cancer treatment

Retinoids used to treat acne and skin problems (such as Accutane or Retin A)

Anticoagulants

Beta-adrenergic blockers used to control blood pressure

Oral contraceptives

CONSENT FOR EYELASH PROCEDURE *

I have agreed to have Le Lash Beautique eyelash extensions applied to and/or removed from my eyelashes. Before my qualified professional can perform this procedure, I understand I must complete this agreement and provide my informed consent by signing and dating where indicated below. For valuable consideration, in order to have my Le Lash Beautique eyelash extensions applied and/or removed from my eyelashes: 1. Waiver of Liability. I understand there are risks associated with having artificial eyelashes applied to and/or removed from my existing 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 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 artificial lashes to my existing eyelashes. Even though the Professional may apply or remove my eyelashes properly, I understand 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 there is more than one technique for applying artificial lashes to my eyelashes, and I will not attribute any liability to the Professional or Le Lash Beautique as a result of this procedure or the use and care of these lashes. I also agree to defend, indemnify and hold harmless the Professional and Le Lash Beautique 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, or my purchase of these Le Lash Beautique products. As used in this agreement, the terms “Professional” and “Le Lash Beautique” include all of their respective officers, directors, agents, employees, successors and assigns. 2. Permission to Use Pictures. I hereby grant to Le Lash Beautique the full right to take, publish and reproduce photographs of me, my face, my 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 Le Lash Beautique. I further expressly assign any copyright in these photographs to Le Lash Beautique. I also grant my consent for Le Lash Beautique to use my image and likeness as contained in these photographs for any advertising or other purposes, along with any comments I may provide. 3. Care and Maintenance. I agree to follow the care and maintenance instructions provided by Le Lash Beautique and/or Professional for the use and care of my artificial lashes and that if any follow up care is required due to my own mistake or negligence, or failure to follow these instructions, this will be at my own expense and risk. I understand that if I do any of the following, it may result in damage to my artificial lashes or may cause my lashes to fall off prematurely. Knowing this I agree to follow these tips for best results: I will avoid oil based eye products as these will loosen the bond of my artificial lashes. I will avoid getting my lashes wet within the first 24 hours after my application. For the first two days after application I understand it is best to avoid swimming, saunas or steam rooms. If I experience any itching or irritation, I agree to contact my Le Lash Beautique Professional immediately to have the lash extensions removed. I agree to avoid using waterproof mascara and to not use an eyelash curler, perm, or tint my artificial lashes. I agree to not pick, pull or rub my artificial lashes. I understand that I should not attempt to remove my lash extensions on my own or with any product, but that the procedure requires that my lash extensions be professionally removed. 4. No Known Medical Conditions / Informed Consent. I have read and completed the Le Lash Beautique Client Intake Form in its entirety and in truth. 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, latex, carbon black 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 to the professional’s or Le Lash Beautique’s instructions or these warnings. If any action is brought to enforce the terms of this Agreement, the prevailing party shall be entitled to its costs and reasonable attorneys’ fees. Any claims arising out of this agreement will be resolved through binding arbitration. This agreement will remain in effect for this procedure, and all future procedures conducted by the Professional or any other professional conducting business at the salon/spa establishment listed above. I agree that this Agreement is binding upon me, and my heirs, legal representatives and assigns. I represent that I am over 18 years of age and that I have the right to enter this agreement, or if I am under 18 years of age, I have had my parent or legal guardian consent to this agreement. By his or her signature below, he or she ratifies and consents to this procedure under these terms.

I Agree

Do Not Agree

Please enter your full name if you agree to the terms and conditions above. *

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(If under 18 ) Parent or Guardian must enter their details below:

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