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PLLV Client Consent Form
PLLV Client Consent Form
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Full Name: _______________________________________________________________________ Phone number: ___________________________________________________________________ E-mail : __________________________________________________________________________ Referred by: ______________________________________________________________________ Allergies: ________________________________________________________________________ Asthma or any respiratory problems? _______________________________________________ Sensitivities? (itchy eye,seasonal hay fever etc.)______________________________________ Are you pregnant? (circle one) Yes No
Do you wear contact lenses?________________________________________________________ Will you remove them during procedure?(circle one) Yes No
Typo of eye makeup remover and mascara? _________________________________________ Prior Eyelash Extension Experience? _______________________________________________ What do you expect from your eyelash extensions? Style,Length etc. __________________________________________________________________________________
Initial
_________ I understand that this procedure requires single synthetic eyelashes to be glued to my own natural eyelashes. I understand that it is my responsibility to keep my eyes closed and be still during the entire procedure, until my eyelash technician addresses me to open my 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 that I may have to latex, surgical tapes, cyanoacrylate, Vaseline, etc. I will seek medical care (at my own expense) and contact Premier Lashes Las Vegas immediately if any allergic or adverse reaction occures. All of my questions were answered and I understand the procedure and risks. _________ I understand that I am required to follow the eyelash extension care sheet in order to maintain the life of these extensions. I understand that eyelash extensions require ongoing maintenance (Refill every 1-3 weeks). If I wait too long between Refills, I may need to pay for a new full set. If I no longer wish to wear the eyelash extension, my technician will remove them and I will not try to remove them myself. _________ I grant permission to Premier Lashes Las Vegas to use my before and after photos for marketing or examples of Premier Lashes Las Vegas work. (Photos are a permanent part of Premier Lashes Las Vegass records, you may opt out) _________ I agree that by reading and signing this consent form, I release Timea Owsley and Premier Lashes Las Vegas from any claims or damages of any nature. I agree that I read and fully understand this entire consent form. I am of sound mind and fully capable of executing this waiver form myself. _________ I understand that this procedure has many variables due to lifestyle, moisture, weather, extreme temperatures, natural eyelash shedding, and other factors. The technician will assess and decide if I am a candidate for this service to the best of their ability. No guarantees are made or implied. For single - strand Eyelash extension services, the undersigned agrees to pay ______ $
___________________________ DATE
________________________ TECHNICIAN
WHAT HAPPENES IS A LASH SHOULD LOOSEN OR BECOME DISLODGED? Do not pull on the lash. Please contact your technician to make an appointment to have them removed or replaced to avoid damage to your natural lashes. As your natural lashes fall out due to the growth cycle, you will need refills when new lashes grow. At first you may find you need a refill every 2 weeks. As you become accustomed to the extensions and with a little practice maintaining the lashes, the time between refills can be extended to 3-4 weeks. We recommend you to book your refill appointment in advance so your spot is guaranteed in the timeframe. ______________ initial
1. Do not perm or Tint lashes before or after lash extension application 2. Do not use a regular eyelash curler. This will break your lashes half. 3. Do not rub your eyes or lashes when washing your face. Clean around the eyes with care 4. Do not pull your lash extensions, as it will take out your own lash as well 5. Do not go in a Sauna while wearing eyelash extensions 6. Do not use regular mascara. We do offer special mascara and eye pencil that was designed to be used with eyelash extensions. 7. Do not use oil based products on your lashes 8. Do not try to remove the extensions on your own 9. Do not cut the extensions, you may cut your own lashes 10. Do use products that are specialy made for eyelash extensions (makeup remover, mascara etc) 11. Remember to come in for touch ups
________________________________ CLIENT
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_____________________________ TECHNICIAN