Date *

MM

DD

YYYY

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthday *

MM

DD

YYYY

Phone *

(###)

###

####

Please indicate if you have recently worn or frequently wear any of the following types of lashes?

Individual

Strip

Flare

Eyelash Extensions

Do you: *

Curl

Perm

Tint

No

Are you having lash extensions applied for:

A special occasion

Daily wear

Are you looking for something... *

A little more natural

A little longer

A little thicker

Dramatic

Much longer

Much thicker

Please check all that apply to you within the last 6 months

Generally relating to the skin

Permanent eye make-up

Blephroplasty (eye lift)

Blepharitis (inflammation of eyelids)

Allergies to adhesives found in bandaids or medical tape

Allergies to cyanoacrylate adhesives (i.e. surgical glue, nail glue, crazy glue) or hypersensitivity to formaldehyde (a by-product released in such adhesives)

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

Please check all that apply to you within the last 6 months

Generally relating to the eye

Lasik eye surgery

Eye illness or injury

Seasonal allergies

Please check all that apply to you within the last 6 months

Generally relating to eyelashes

Hormone imbalance or extreme stress

Recent sever illness or major injury

Pregnancy and/or recent childbirth

New prescription or recently prescribed oral contraceptives

Types of medical conditions that may contribute to hair and eyelash loss: Hyperthyroidism or Hypothyroidism Alopecia Areata, Lupus, Diabetes

Vitamin and mineral deficiencies that may contribute to hair and eyelash loss: A, B, Selenium, Zinc, Iron, Frolic, Acid

Trichotillomania (hair pulling disorder)

Medications that may contribute to hair or eyelash loss: Chemotherapeutic agents used in cancer treatment, Anticoagulants (blood thinners), Beta blockers (used to control blood pressure)

By clicking "Accept" I understand that the Items I have checkedabove may increase the risks involved in having eyelashes applied and/or removed and do hereby give my consent for the procedure. I further agree to inform my lash stylist if any of the above conditions have changed prior to proceeding with the service in any future appointments. *

Accept

CONSENT FOR EYELASH PROCEDURE

I have agreed to have Lavish Lashes 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 selecting "Accept and Consent to Treatment Procedure" and dating where indicated below.

For valuable consideration, in order to have my Lavish Lashes 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 not withstanding the utmost of care in the application or removal of these products, there still exists 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 Lavish Lashes to my existing eyelashes. Even though the Professional may apply or remove my Lavish Lashes 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 Lavish Lashes to my eyelashes, and will not attribute any liability to Professional or Lavish Lashes as a result of this procedure or the use and care of these lashes. I also agree to defend, indemnify and hold harmless Professional and Lavish Lashes from any and all calims, actions, expenses, damages and liabilities, including reasonable attorneys' fees which might be asserted against them as a result of having this procedure performed, or my purchase of these Lavish Lashes products. As used in this Agreement, the terms "Professional" and "Lavish Lashes" include all of their respective officers, directors, agents, employees, successors and assigns.

2. Permission to Use Pictures

I hereby grant to Professional and Lavish Lashes the full right to take, publish an 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 Lavish Lashes. I further expressly assign any copyright in these photographs to Lavish Lashes. I also grant my consent for Professional and Lavish Lashes to use my image and likeness as contained in these photogaraphs for any advertising or other purposes, along with comments I may provide. Please use these images with the following: *

My own name

No name to be used

A fictitious name