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Lash Consent Form, Schemes and Mind Maps of Life Sciences

University of California - Los Angeles (UCLA)Life Sciences

PLEASE NOTE USE OF OIL BASED PRODUCTS AROUND EYES SHOULD BE DISCONTINUED FOR 48. HOURS AFTER YOUR EYELASH EXTENSION SERVICE. It is also recommended to avoid ...

Typology: Schemes and Mind Maps

2022/2023

Uploaded on 02/28/2023

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Eyelash(Extension(Consent(Form(-((Alison(Andrews(Day(Spa(
I""have"agreed"to"have"eyelash"extensions"applied"and/or"removed"from"my"eyelashes.""Before"
my"professional"eyelash"technician"can"perform"this"procedure,"I"understand"I"must"complete"
this"agreement"and"provide"my"consent"by"signing"and"dating"this"consent"form."""
Client(Information:!
Name:!
___________________________________________________________________________!
Address:!
_________________________________________________________________________!
City:________________________________State:_______! Zip:_______________!
Phone:! ___________________________!
Email:________________________________________!
How!did!you!hear!about!
us:__________________________________________________________!
Birthday:!!Month!and!Day!:!!_______Month!_______Day!(!we!have!birthday!coupons!!)!
Is!this!your!first!time!having!Eyelash!Extensions?!!____Yes!!_____No!
If!yes,!please!let!us!know!about!your!experience!and!approximately!how!long!ago!you!had!your!
last!
service.________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________!
Are!you!having!lash!extensions!applied!for:!!_______Special!Occasion!-or-!_______Daily!Wear!
Do!you!wear!Contacts?!!______Yes!______!No!
Do!you!have!ANY!make!up!around!your!eyes!today?!!________Yes!_______No!
Do!you!often!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!
Please!list!any!eye!drops!or!eye!medication!you!are!currently!using._______________________!
Are!you!able!to!lay!on!your!back!for!2!hours!to!have!your!lashes!applied?!______Yes!_____No!
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Eyelash Extension Consent Form - Alison Andrews Day Spa I have agreed to have eyelash extensions applied and/or removed from my eyelashes. Before my professional eyelash technician can perform this procedure, I understand I must complete this agreement and provide my consent by signing and dating this consent form. Client Information: Name:

Address:

City:________________________________State:_______ Zip:_______________ Phone: ___________________________ Email:________________________________________ How did you hear about us:__________________________________________________________ Birthday: Month and Day : _______Month _______Day ( we have birthday coupons! ) Is this your first time having Eyelash Extensions? ____Yes _____No If yes, please let us know about your experience and approximately how long ago you had your last service.________________________________________________________________________

Are you having lash extensions applied for: _______Special Occasion -or- _______Daily Wear Do you wear Contacts? ______Yes ______ No Do you have ANY make up around your eyes today? ________Yes _______No Do you often 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 Please list any eye drops or eye medication you are currently using._______________________ Are you able to lay on your back for 2 hours to have your lashes applied? ______Yes _____No

Will you be able to keep your eyes completely closed for up to 2 hours? ______ Yes _____No Are you pregnant? _________ Yes _________ No What other products do you currently use around your eyes? ( eye creams, oinments, lash growers, etc.)

_ PLEASE NOTE USE OF OIL BASED PRODUCTS AROUND EYES SHOULD BE DISCONTINUED FOR 48 HOURS AFTER YOUR EYELASH EXTENSION SERVICE. It is also recommended to avoid all oil based products around your eyes for as long as you wear your lashes. Oil based products, waterproof mascaras and liners will loosen the adhesive and your lashes will not last long. Please initial and date you read and understand the above. ___________Initial_________Date For longevity we recommend not to use mascara ( you're lashes will look so glamorous you won't feel a need to), however if you must, be sure it is oil free and remove it daily with an oil free wash. We recommend our eye wash, or you can may use Sterild or Occusoft ( available at most drug stores). Please initial and date you read and understand the above _________Initial __________Date Do you use lash growers such as Lattice or over the counter ones? ________Yes ________No It is best to discontinue use of these 2 weeks before you service and discontinue use while you are wearing your lash extensions. Some contain oils and/or steriods and will shorten the duration of your extensions. How do you usually sleep? _______Side __________Back __________Stomach Please note you will lose more eyelash extensions on the side on which you sleep. Sleeping on your stomach will affect them the most and it is important to refrain from sleeping on your stomach for the first 2 days after your service to allow the adhesive to set properly. The following conditions are not suitable for eyelash extensions. Possible adverse reactions are listed below each condition. Are you allergic to adhesives ( glues, tapes, band aids, etc)? ____________Yes __________No This service may use adhesives tapes, glues and gel pads thaty may cause an allergic reaction. We use a medical grade, formaldehyde free glue, but allergies may still occur. Have you had Chemotherapy Treatments in the last 6 months? _________Yes _________No Medication for chemotherapy may cause a reaction to the materials used in this service. Also, if lashes are just starting to grow back they may be a little weak and we recommend waiting until they are strong enough for this service.

I release my certified lash technician and Alison Andrews Day Spa from any and all liability associated with this procedure. This service will be performed with the utmost attention to safety, sanitation and proper application using tools and products that the technician has been trained and certified to use. This service has many variables due to lifestyle, moisture, weather, extreme tempatures, natural eyelash shedding and other factors. The technician ( along with my consent form and consultation) will decided if I am a good candidate for this serive to the best of their ability. _____________ Initial. By signing below, I verify that I have read and understand the above statemetns and agree to them. Thank you for the time you took to read, understand and agree to our consent form. Client Signature_________________________________________________ Date_____________ Technician Signature_____________________________________________Date______________