How did you hear about Lashious?
Advertisement Google/Web Referral: First/last name: ____________________ Other: _____________
Have you worn any of the following?
Strip Flare Eyelash extensions: Type / Length / Thickness: __________________________ None
Do you: Curl Perm Tint None
Why are you having extensions applied?
A special occasion: Date: ___________ Daily wear Mascara Replacement: Coats: _______ Other
How would you like your extensions?
Natural A little longer A little thicker Dramatic Much longer Curly
Do you wear contacts? Yes or No Do you wear glasses? Yes or No
|Please check off any items that may apply to you within the last 6 months:|
|Lasik eye surgery||Hormone imbalance or extreme stress|
|Eye illness or injury||Severe illness or major injury|
|Allergies: List below (seasonal etc)||Pregnancy or recent child birth|
|Permanent eye makeup||Vitamin or mineral deficiencies (A, B, zinc, iron, folic acid, selenium)|
|Blepharitis (inflammation of eyelids)||Medical condition that contributes to hair loss (hyperthyroidism, alopecia, lupus, diabetes)|
|Allergies to band-aids or medical tape|
|Retinoids used to treat acne (accutane)||Medication that contributes to hair loss (Chemotherapy, anticoagulants, beta blockers)|
|Allergies to adhesives (cyanoacrylate, surgical glue, nail glue, crazy glue, formaldehyde)|
CONSENT FOR LASHIOUS PROCEDURE:
I have agreed to have cosmetic procedures, including but not limited to, eyelash extensions applied to and/or removed from my eyelashes. Before my qualified professional can perform such procedure(s), I understand that I must complete this agreement and provide my informed consent by signing and dating where indicated below. For valuable consideration, in order to receive cosmetic procedures, including but not limited to, eyelash extensions applied and/or removed:
- Waiver of Liability. I understand there are risks associated with cosmetic procedures, including but not limited to, having artificial eyelashes applied to 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 the eyelash extension 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 lash extensions 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 that there is more than one technique for applying eyelash extensions to my eyelashes, and I will not attribute any liability to the Professional or Lashious Inc, 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 Lashious Inc, from any and all claims, actions, expenses, damages and liabilities, including reasonable attorney’s fees which might be asserted against them as a result of having this procedure performed, or my purchase of these products. As used in this agreement, the terms “Professional” and “Lashious Inc” include all of their respective officers, directors, agents, employees, successors and assigns.
- Permission to Use Pictures. I hereby grant to Professional and Lashious Inc, 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 Professional or Lashious Inc. I further expressly assign any copyright in these photographs to Lashious Inc. I also grant my consent for Professional or Lashious Inc to use my name, image and likeness as contained in these photographs for any advertising or other purposes, along with any comments I may provide.
- Care and Maintenance. I agree to follow the care and maintenance instructions provided by Lashious Inc and Professional for the use and care of my cosmetic procedure(s), including but not limited to, 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 eyelash extensions 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 extensions. 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 Lashious 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 on my eyelash extensions. I agree not to pick, pull or rub my extensions. I understand that I should not attempt to remove my lash extensions on my own or with any product as this procedure requires a lash Professional for removal.
- No Known Medical Conditions / Informed Consent. I have read and completed the Lashious Inc: Intake and Consent Form in its entirety and in truth. I acknowledge that I have been advised of the potential harmful or negative side effects of the cosmetic procedures, including but not limited to, the premature shedding of my eyelash, that the lash extension procedure or removal may cause to those who have specific medical or skin condition. 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 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 or Lashious Inc instructions of these warnings.
- Cancellation & Late Policy. A) In order to provide our clients with the highest quality service, we require a minimum of 24 hours cancellation notice prior to the appointment. Failure to do so will result in a cancellation fee. The fees are as follows: 1 Hour service – $45.00 Fee; 2 Hour service – $85.00 Fee; Less than one hour – 50% Fee. B) Should you be running late, your appointment will be held for 15 minutes, provided we hear from you. If you are more than 15 minutes late for your service, your appointment will need to be rescheduled. At this point your appointment will be given up to someone on our cancellation list. Please keep in mind that each appointment is booked for a set amount of time. If you are late, you will be cutting into your own appointment time. So please do your best to be punctual. By signing this agreement Lashious Inc. is authorized to charge the credit card on file in accordance with our cancellation and late policy.
If any action is brought to enforce the terms of this Agreement, the prevailing party shall be entitled to its costs and reasonable attorney’s fees. Any claims arising out of this agreement will be resolved through binding arbitration using the rules of the Canadian Arbitration Association.
This agreement will remain in effect for this procedure, and all future procedures conducted by Professional or any other professional conducting business at the establishment listed within this agreement.
I agree that this Agreement is binding upon me, and my heir, 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, and his or her name and relationship is to me is as follows:_______________________________, _______________________________. By his or her signature below, he or she ratifies and consents to this procedure under these terms.