CLIENT CONSENT FORM

CLIENT CONSENT FORM

CLIENT NAME:____________________________________________________________________________________________________________

ADDRESS:__________________________________________________________________________________________________________________

CITY:____________________________________________________STATE:________________ZIP:___________________________________

PHONE:_______________________________________________________________________________________________________________________

E-Mail:________________________________________________________________________________________________________________________

I understand that there are risks associated with having artificial eyelashes applied to and/or removed from my

natural lashes.

I understand that the eyelash extensions will be applied to the natural lash as determined by the technician so

as not to create excessive weight on the natural eyelash thereby preserving the health, growth and natural

look of the client’s natural eyelashes.

I understand that as part of the procedure, eye irritation, pain, itching discomfort and in rare cases, eye

Infection my occur.

I understand and agree that if I experience any of these issues with my lashes I will contact my technician and

have the eyelash extensions removed immediately and consult a physician at my own expense.

I understand and agree to the follow the aftercare instructions provided by my technician. Failure to follow

the aftercare instructions may cause the eyelash extensions to fall out.

I understand that in order to have the eyelash extensions applied to my eyelashes, I will need to keep my eyes

closed for duration of 60-180 minutes during the procedure. I also understand that I will nee to be lying in a

reclined position. Any medical conditions that might be aggravated by lying still for a prolonged period of time

may mean that I will not be able to have the procedure performed on my eyes.

I agree to use only recommended products on my Eyelash Extensions.

I acknowledge that I should not pull on my lashes after they have been applied.

I understand that there is a potential possibility of allergic reaction– as with all cosmetic products.

I understand this service is non-refundable.

How did you hear about us?_______________________________________________________

Is this the first time you have had lash extensions applied? Yes No

Do you curl perm tint your lashes No

Are you having lash extension 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

What side do you predominately sleep on? Right Left

Please list any eye drops or eye medications you are using_______________________________________________

Are you able to keep your eyes closed and lie still for up to 2 hours or longer? Yes No

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CLIENT NAME:____________________________________________________________________________________________________________

ADDRESS:__________________________________________________________________________________________________________________

CITY:__________________STATE:ZIP:_

PHONE:_______________________________________________________________________________________________________________________

E-Mail:________________________________________________________________________________________________________________________ I understand that there are risks associated with having artificial eyelashes applied to and/or removed from my natural lashes. I understand that the eyelash extensions will be applied to the natural lash as determined by the technician so as not to create excessive weight on the natural eyelash thereby preserving the health, growth and natural look of the client’s natural eyelashes. I understand that as part of the procedure, eye irritation, pain, itching discomfort and in rare cases, eye Infection my occur. I understand and agree that if I experience any of these issues with my lashes I will contact my technician and have the eyelash extensions removed immediately and consult a physician at my own expense. I understand and agree to the follow the aftercare instructions provided by my technician. Failure to follow the aftercare instructions may cause the eyelash extensions to fall out. I understand that in order to have the eyelash extensions applied to my eyelashes, I will need to keep my eyes closed for duration of 60-180 minutes during the procedure. I also understand that I will nee to be lying in a reclined position. Any medical conditions that might be aggravated by lying still for a prolonged period of time may mean that I will not be able to have the procedure performed on my eyes. I agree to use only recommended products on my Eyelash Extensions. I acknowledge that I should not pull on my lashes after they have been applied. I understand that there is a potential possibility of allergic reaction– as with all cosmetic products. I understand this service is non-refundable. How did you hear about us?_______________________________________________________ Is this the first time you have had lash extensions applied? Yes No Do you curl perm tint your lashes No Are you having lash extension 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 What side do you predominately sleep on? Right Left Please list any eye drops or eye medications you are using_______________________________________________ Are you able to keep your eyes closed and lie still for up to 2 hours or longer? Yes No

This agreement will remain in effect for this procedure and all future procedures conducted by my technician. I understand that this agreement is binding and that I have read and fully understand all information above. I represent that I am over the age of 18 years. If below 18 years of age a parent or guardian must also sign this form. _By signing below, I verify that I have read and understand the above statements and agree to them. Client Signature: ____________________________________________________ Date: _____________________ I have agree to have eyelash extensions applied to and/or removed from my eyelashes. Before my qualified professional can per- form the procedure, I understand I must complete this agreement and provide my informed consent by signing and dating where indicated below.

Waiver of Liability. I understand that 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 lases to my existing eyelashes. Even though the pro- fessional may apply or remove my lashes properly, I understand adhesive material may become dislodged during or after the procedure, which may irritate y eyes or require further follow-up care, at my own expense to prevent damage to my eyes. I also agree that I will not attribute any liability to Professional as a result of this procedure or the use and care of these lashes. I also agree to defend, indemnify and hold harmless Professional from any and all claims, actions, expenses, damages and lia- bilities, including reasonable attorney’s fees which might be asserted against them as a result of my having this procedure per- formed. I understand that there are no refunds.
Care & Maintenance. I agree to the follow the care and maintenance instructions provided by Novalash and/or Professional for the use and care of my eyelash extensions and that if any follow up care is required due to my own mistake or negligence, or failure to follow these instruction's, 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 extensions or may cause my lashes to fall off prematurely. Knowing this I agree to follow these tips for best results. I will avoid using waterproof mascara on my eyelashes and to not use an eyelash curler, perm or tint my extensions. I have been advised that using mascara on a regular basis will shorten the length of time my extensions will re- main in place. If I experience any itching or irritation, I agree to contact my Professional immediately to have the lash exten- sions removed. I agree to not pick, pull or rub my Extensions. I understand that I should not attempt to remove my lash exten- sions on my own or with any product, but that the procedure requires that my lash extensions be professionally removed.
No Known Medical Conditions/ Informed Consent. I have read and completed the consent form in its entirety and in truth I acknowledge that I have been advised of the potential harmful or negative side effects (such as premature shedding of my eyelash) that the lash extension procedure or removal may cause to those who have specific medical or skin conditions. I un- derstand 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. 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 exten- sion 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 instructions or these warnings. If any action is brought to enforce the terms of this Agreement, the prevailing party shall be entitles to its costs and reasonable attorney’s fees. This agreement will remain in effect for this procedure, and all future procedures conducted by Professional. 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, ad his or her relationship to me is as follows;__________________________ By his or her signature below, he or she ratifies and consents to this procedure under these terms. Signature:____________________________________________________________ Date:________________________ Print Name:________________________________________________________________________ Parent/Guardian Signature:_______________________________________________ Date:________________________ Print Name:_________________________________________________________________________

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