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Course Request Form
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Release Form

Contact Information

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Eyelash ExtensionsPermanent Makeup

Model/Brand Ambassador

YesNo

IndividualStripeFlareOther

CurlPermTintNone

Special OccasionEvery Day Wear

Visiting from out of townWear ContactsHabitually rub, pull, or pick your lashesEver been treated for any eye illness or injuryAble to keep your eyes closed and lie still for up to 2 hours or longer?

Lasik Eye SurgeryPermanent Eye MakeupBlephroplasty (eye lift)Allergies to adhesives or syntheticsChild birth within last 120 daysAlopeciaThyroid diseasesAllergic to GlycerinHypersensitivity to cyanoacrylate or formaldehyde or certain adhesives/gluesRecent high fever or severe illnessIron DeficiencyHormonal imbalance or extreme stressExposure to certain chemicals found in swimming pools, and to bleach, dye and perm hairMajor surgery within last 120 daysEating DisordersDrugs that can cause temporary hair lossChemotherapeutic agents used in cancer treatmentRetinoids used to treat acne and skin problems (such as Accutane or Retin A)AnticoagulantsBeta-adrenergic blockers used to control blood pressureOral contraceptivesNone

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CONSENT FOR EYELASH PROCEDURE:

I have agreed to have eyelash extensions applied to and/or removed from my eyelashes. Before my qualied professional can perform this procedure, I understand I must complete this agreement and provide my informed consent by signing and dating where indicated below.

For valuable consideration, in order to have my eyelash extensions applied and/or removed from my eyelashes:

1. Waiver of Liability. I understand there are risks associated with having articial eyelashes applied to and/or removed from my existing 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 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 articial to my existing eyelashes. Even though the Professional may apply or remove my 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 to my eyelashes, and I will not attribute any liability to Professional or LLC 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 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 products. As used in this agreement, the terms “Professional” and “ , LLC” include all of their respective ocers, directors, agents, employees, successors and assigns.

2. Permission to Use Pictures. I hereby grant to Professional and , 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 Professional or , LLC. I further expressly assign any copyright in these photographs to , LLC. I also grant my consent for Professional and , 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:

CONSENT FOR EYELASH PROCEDURE:

My own nameNo name usedFictitious name

3. Care and Maintenance. I agree to follow the care and maintenance instructions provided by , LLC and/or Professional for the use and care of my , and that if an y 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 y cause my lashes to fall o prematurely. Knowing this I agree to follow these tips for best results: I will avoid oil based eye products as these will loosen the bond of my I will avoid getting my lashes wet within the rst 24 hours after my application. For the rst two days after application I understand it is best to avoid swimming, saunas or steam rooms. If I experience any itching or irritation, I agree to contact my rofessional 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 I agree to not pick, pull or rub my I understand that I should not attempt to remove my lash extensions on my own or with any product, but that the procedure requires that my lash extensions be professionally removed.

4. No Known Medical Conditions / Informed Consent. I have read and completed the 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 eyelash) that the lash extension procedure or removal may cause to those who have specific medical or skin conditions. I understand that the adhesives and adhesive remover are a skin, eye and mucus membrane irritant and that in rare cases persons may be allergic or have hypersensitivity to synthetics, cyanoacrolate or formaldehyde which in small amount may be present 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 known medical condition that might be aggravated by the procedure or any medical condition that would prevent me from complying with or heeding to the professional’s or instructions or these warnings.

If any action is brought to enforce the terms of this Agreement, the prevailing party shall be entitled to its costs and reasonable attorneys’ fees. Any claims arising out of this agreement will be resolved through binding arbitration using the rules of the American Arbitration Association.

This agreement will remain in effect for this procedure, and all future procedures conducted by Professional or any other professional conducting business at the salon/spa establishment listed above.

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 this agreement, or if I am under 18 years of age, I have had my parent or legal guardian consent to this agreement. By his or her signature below, he or she raties and consents to this procedure under these terms

Permanent Makeup Section

Beauty MarkBody ArtEyelinerLiplinerLip ShadingFull Lip ColourLash IllusionAreola RepigmentationNeedlingCorrective Pigment CamouflageEyebrow Hair SimulationCorrection or Repair

Please check the box if you answer yes to any of these questions.

Are you allergic to penicillin or any other drugs?Do you have any kid of heart condition?Do you take any recreational drugs?Do you take Zovirax, Valtrex or Famvir?Have you ever had Alloderm, Silicone, Dermagin, Gortex, lip implants or other substances placed into your lips?Do you intend to have any fillers or laser on or in your face after your lip colour application?Have you ever had chicken pox?Do you have TMJ or any mouth problems?None Of The Above
Are you allergic to any insect stings?Are you prone to, or have any keloid scars?Do you get fever blisters or cold sores?Do you currently have an outbreak?Have you ever had cold sores around the eye area?Do you wear contact lenses, have implants or any eye problems?Are you allergic to novicaine or any "caine" anesthesia?Are you allergic to or ever had a reaction to Polysporin, Bacitracin, Neosporin, A&D, Vaseline or any other antibiotic, or topical healing ointments or products?None Of The Above

YesNo

YesNo

YesNo

Consent to Patch TestWaive Patch Test

I fully understand that a consultation fee of $50.00 will be deducted from my deposit in the event of cancellation of said procedure. The entire staff is dedicated to client satisfaction. We employ a no refund policy and I am aware of this.

I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results. Subsequent visits are subject to $100/$300 charge depending upon the amount of work needed. There is a possibility of an allergic reaction to pigments. A Patch Test is recommended; if waived, I release the technician and assistants from liability if I develop an allergic reactionto the pigment. (Pigment contents are: iron oxide, lakes, alcohol, Glycerine and distilled/sterile water.)

I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure. For the purpose of documentation, I also consent to
the taking of before and after photographs/videos of said procedure which become our sole property and may or may not be used by the technician, salon or clinic. I am aware that cosmetic procedures including but not limited to: Gortex, Alloderm, Fat Transference, Dermagin, Silicone or any other substance injected into or around the lip tissue AFTER having lipliner or full lip colour, may compromise the existing procedure boundaries. Laser treatments may also compromise your permanent cosmetic make-up application.

I have read the above and had explained to me and fully understand this consent and procedure form: That the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following the cosmetic procedures which is to be performed at my request according to this consent and procedure form. I also understand that this procedure is permanent.

I will follow all ’ After Care’ instructions explicitly. Failing to do so will compromise my final results. Please click here for PDF of aftercare instructions.

I authorize B-Lashes, LLC to perform the elective cosmetic pigmentation procedure understanding that this procedure is for cosmetic purposes only and not for health reasons. If any unforeseen conditions arise in the course of this procedure calling for his/her judgment for procedures in addition to, or, different from those now contemplated, I further request and authorize him/her to do whatever necessary in the circumstances. I am aware that no guarantees have been made to me concerning the results of the procedure(s).

I also understand that the permanent skin pigmentation procedure carries with it the possible complications and consequences associated with this type of cosmetic procedure, which includes risk of infection, scarring, eye damage, inconsistent colour, hemorrhage, and possible spreading, fanning or fading of pigments and or allergic reaction to any products used. I understand the actual colour of the pigment may be modified slightly due to the tone and colour of my skin. I am aware that cosmetic procedures including but not limited to: Gortex, Alloderm, Fat Transference, Dermagin, Silicone or any other substance injected into or around the lip tissue AFTER having lipliner or full lip colour, may compromise the existing procedure boundaries. Laser treatments may also compromise the permanent cosmetic make-up application. I fully understand as with all such procedures that this is not a science but rather an art and that anything that can go wrong may go wrong. I request the permanent skin pigmentation procedure, appreciating and accepting the permanency of the procedure as well as the possible complications and consequences of the said procedure(s).

For the purpose of documentation, I also consent to the taking of before, during and after photographs / videos of said procedure(s) which become the technician's sole property and may or may not be used for what ever purpose deemed necessary. Understanding the permanent skin pigmentation procedure, the procedure, the permanency of the procedure, the possible consequences of the procedure, and that the procedure is for cosmetic purposes only.

I certify that I have read the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedure(s) which is to be performed at my request according to this consent were filled in before I signed this statement.

Signature

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