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Eyelash Extensions Intake and Consent Form
Address Line 2
State / Province / Region
ZIP / Postal Code
Antigua and Barbuda
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
British Indian Ocean Territory
Central African Republic
Congo, Democratic Republic of the
French Southern Territories
Heard Island and McDonald Islands
Isle of Man
Korea, Democratic People's Republic of
Korea, Republic of
Lao People's Democratic Republic
Northern Mariana Islands
Palestine, State of
Papua New Guinea
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
South Georgia and the South Sandwich Islands
Svalbard and Jan Mayen
Syria Arab Republic
Tanzania, the United Republic of
Trinidad and Tobago
Turks and Caicos Islands
US Minor Outlying Islands
United Arab Emirates
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Is this the first time you have had lash extensions applied?
If No, where have you had them applied?
If No, what brand was used?
Please indicate if you have worn within the last 60 days any of the following types of lashes:
Do you curl perm or tint your lashes?
Are you having lash extensions applied for:
A Special Occasion
Do you have or are you being treated for any eye illness or injury?
List any eye drops or eye medication that you’re using:
1. WAIVER OF LIABILITY:
I understand there are risks associated with having artificial lashes applied to and/or removed from my existing, natural 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 the product itself, which include without limitation, eye irritation, eye pain, discomfort and in rare cases blindness when improperly handled. As part of the procedure, I understand that a certain amount of eyelash adhesive material will be used to attach the lash extensions to my existing eyelashes. Even though the Professional will take the utmost care to apply or remove my lash extensions properly, I understand that 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 are more then one technique for applying eyelash extensions to my eyelashes and I will not attribute any liability to the Professional or to ReneeJean Make-up, LLC. from any and all claims, actions, expenses, damages and liabilities, including reasonable attorneys’ fees which might be asserted against them as a result of my having this procedure performed, or my purchase of these eyelash extensions or products. As used in this agreement, the terms Professional and ReneeJean Make-up, LLC. includes all of their respective officers, directors, agents, employees, successors and assigns.
2. PERMISSION TO USE PICTURES:
I hereby grant to Professional and ReneeJean Make-up, LLC. 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 ReneeJean Make-up, LLC. I further expressly assign any copyright in these photographs to ReneeJean Make-up, LLC. I also grant my consent for ReneeJean Make-up, LLC. to use my image and likeness as contained in these photographs for any advertising or other purposes, along with any comments I may provide.
Please use these images with the following:
My own name.
No name to be used.
3. CARE AND MAINTENANCE:
I agree to follow the care and maintenance instructions provided by ReneeJean Make-up LLC. and/or Professional for the use and care of my eyelash extensions and 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 eyelashes to fall out prematurely. Knowing this I agree to follow these tips for best results: I will avoid oil based eye products as these will loosen and breakdown the bond/adhesive of my eyelash extensions. I will avoid getting my eyelash extensions wet within the first 24 hours after my application. For the first 2 days after my application I understand that it is best to avoid swimming, saunas and steam rooms. If I experience any itching or irritation I agree to contact my ReneeJean Make-up, LLC. 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 my eyelash extensions. I agree to not pick, pull or rub my eyelash extensions. I understand that I should not attempt to remove my eyelash extensions on my own or with any product, but that the procedure requires that my eyelash extensions be professionally removed.
4. NO KNOWN MEDICAL CONDITION/INFORMED CONSENT:
I have read and completed the ReneeJean Make-up, LLC. Care Client Intake Form in its entirety and in truth. I acknowledge that I have been advised of the potential harmful or negative side effects (such as the premature shedding of my eyelashes) that the lash extension procedure or removal may cause to those who have specific medical or skin conditions. I understand that the adhesive and adhesive remover are a skin, eye and mucus membrane irritant and that in rare cases persons may be allergic or may have hypersensitivity to synthetics, cyanoacrolate or formaldehyde which in small amounts may be 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 medical condition that might be aggravated by the procedure or any medical condition that would prevent me from complying with or heeding to the Professionals or ReneeJean Make-up, LLC. instructions or these warnings. This agreement will remain intact for this procedure, and all future procedures conducted by Professional conducting services under the name of ReneeJean Make-up, LLC. 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 into 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 relationship to me is as follows:
I agree to only use products recommended by my eyelash extension technician.
I understand that I cannot get my eyelash extensions wet within 24 hours after application.
I understand that there are many variable, including technician expertise, hair growth cycle, use of cosmetics and skincare products and the overall care given that will influence how long my eyelash extensions remain in place.
I acknowledge that I should not rub or pull on my lashes after extensions have been applied.
I understand that if eyelash extensions are not applied properly by a certified technician there is greater risk of eye damage and harm to my vision.
I understand, as with all cosmetic products, there is a potential possibility of allergic reaction.
I have been advised that using mascara will shorten the time my extensions remain in place. I have also been advised not to use waterproof mascara or mascara that contains any glycol ingredients.
I understand that touch-up appointments may be necessary as soon as two weeks after the application.
I have read and discussed the above information with my certified eyelash technician.
I authorize ReneeJean Make-up, LLC. to apply the eyelash extension product to my own eyelashes.