LASHES FOR DAYS CUSTOMER INFORMATION & WAIVER

LASHES FOR DAYS CUSTOMER INTAKE & CONSENT FORM

Thank you for considering us to be your lash service provider. So that we provide you with best service possible, please first complete and sign the form below.
Customer Information
Today's Date*

MonthDayYear
Date
Name*

First NameLast Name
Email*
example@example.com
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Would you like to receive promotional emails from us?

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Mobile Phone Number*

Area CodePhone Number
Date of Birth - Must be 18+*

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?*

Family/FriendFacebookGoogle searchInstagramOther
Have you had any lash treatments before? Choose all that apply*

Lash ExtensionsLash Lift (perm)Lash TintNone of the above
Do you currently have extensions on?*
If you currently have extensions on, how long ago has it been since your last fill (or full set if you haven't yet had a fill)
BEAUTY REGIME - Please check all of the below products you currently use

Lash growth serumEyelash curlerWaterproof or regular mascaraOil-based products (serums, creams, removers etc.)‎EyelinerStrip or false lashes
The Lash Salon is located in the lower level of a house. Are you physically able to walk up and down one flight of stairs?

YesNo
A dog lives in the house where the Lashes For Days studio is located. Do you expect this to be a problem (allergies, fear of barking wiener dogs etc.)?*

Nope!Yes
Which side do you normally sleep on?*
I allow the professional to take photos of my eyes before and after my lash treatment for my file or any other professional use.*

Yes for bothFor my file only
Health History
Are you sensitive to scents?*

Yes, highly sensitiveYes, slightly sensitiveNo, not at all
CONDITIONS RELATING TO THE EYE - Please check any that apply to you.

I wear glassesI wear contact lensesEye surgery‎Eye illness or injuryDry eyesSeasonal allergiesEye infectionPermanent eye makeupBlepharitis (infammation of eyelids)‎Allergies to adhesives found in band-aids or medical tape‎Allergies to cyanoacrylate adhesives (i.e. surgical glue, nail glue, crazy glue)‎Allergy to under eye gel pads
CONDITIONS GENERALLY RELATING TO THE EYELASHES - Please check any that apply to you.

Damaged or frail lashesHormone imbalance‎Recent severe illness or injury‎Pregnancy or recent childbirth‎New prescriptions or recently prescribed oral contraceptives‎Types of medical conditions that may contribute to hair and eyelash loss: hyperthyroidism or hypothyroidism, alopecia areata, lupus, diabetes‎Vitamin and mineral deficiencies that may contribute to hair and eyelash loss: A, F, B, Selenium, Zinc, Iron‎Trichotillomania (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)‎A condition that doesn't allow you to lay still with your eyes closed for up to 2 hours
Any other information we should know about? Please also indicate here if you'd prefer to have a patch test done 24-48 hours before your initial appointment.
Authorization
I understand that this procedure requires single synthetic eyelashes to be adhered to my own natural eyelashes and is semi permanent.

I understand that what I want may not be identical to pictures I have seen, as my natural lashes will be the guide to the amount, length, curl and thickness of extensions I can receive.

I understand that it is my responsibility to keep my eyes closed and be still during the entire procedure, since tweezers and glue are by the eyes.

I understand that some risks of this procedure may be but not limited to eye redness and irritation. The fumes from the adhesive may cause my eyes to tear up if I open my eyes.

I agree to disclose any allergies I have to surgical tapes, cyanoacrylate, creams etc.

I agree that by reading and signing this consent form, I release Lashes For Days from any claims or damages of any nature.

I agree to inform Lashes For Days of any health changes in the future, including pregnancy and that this agreement remains in effect for all future visits.

I understand that an allergic reaction is possible from the adhesive causing redness along the eyeline and swollen eyes. An allergic reaction could happen immediately, a few months, or years later or not at all, however; I am fully aware that this is a possibility. I will contact Lashes For Days with a reasonable amount of notice for a patch test 24-28 hours before my appointment if I feel it is necessary.

I understand that I requested for the service and a trained professional will perform the service to their highest standard. If a reaction does occur, I agree to contact Lashes For Days to have them removed at no charge and I also understand that a refund will not be provided.

I agree to follow the aftercare recommendations given by my technician and understand I am fully responsible for the maintenance of my lashes.

I am aware that at least 24 hours is required to cancel or reschedule an appointment.

I understand that this is a beauty service and no refunds are given.
WAIVER - Please read
I agree to all of the above and that all information provided to be true.*

Yes
Your Digital Signature*

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LASHES FOR DAYS CUSTOMER INTAKE & CONSENT FORM

Customer Information

Health History

Authorization