CLIENT INFORMATION FORM/INDEMNITY

Name: ______ID Number______

Date of first visit: ______Referred by: ______

Procedure: ______

Postal address: ______

Telephone number(s): Cell: ______Home: ______Work: ______

Occupation: ______

Do you suffer from any conditions on the list below?

Condition / Yes / No
Claustrophobia
Asthma
Epilepsy
Heart disease
Back problems
Diabetes
High/low blood sugar
Eye stye
Pink eyes
Warts or Moles on eye area
Sensitive eyes
Blepharitis

All present medication: ______
______

The nature and method of the eyelash extensions procedure has been fully explained to me, the usual risk inherent in the procedure and the possibility of complications during and after its performance as listed below:

! The glue contains fumes & may cause an allergic reaction in certain instances, never open your eyes during the application as the bonder and the fumes may cause damage to the eye and cause temporarily or permanent blindness.

! The bonder takes approximately 24 hours to set therefore you must not wet your eyelashes, wear makeup, rub your eyes or participate in any activities such as sports, sauna & Jacuzzi.

! There are some products that can influence the eyelashes and how long it will last: medication, makeup removers, stress, mascara, hair growth cycles and skin care products.

! No oily products must be used on the lashes as this will loosen the false from the natural lash.

! Eyelashes should not be permed or tinted prior to the application.

! It is recommended that you come in for a maintenance fill every 2-3 weeks.

! Not all hair are the same stage of growth, therefore some lashes will fall out before the rest, this is not due to improper application.

! Never try to remove the lashes yourself, lashes must be removed by the therapist with the proper products and care otherwise you will damage your natural lashes.

I understand that I have the option of receiving a patch test at least 24 hours prior to the procedure, if I waive the right to such test I will be fully responsible for any consequences of any allergy that may occur associated to the application of Eyelash Extensions.
I undertake not to make a claim against (Therapist and salon name) ______and do hereby indemnify and hold the said business, its Owner and Employees harmless in respect of any claim or damage suffered by me in the consequence of using the Eyelash Extensions procedure.

SIGNED AT ______ON THE ______DAY OF ______20______

Client Signature: ______

Witness:______