BeautyPOP Studio Lash Clients Appointment Form * First Name Last Name Email * Phone * (###) ### #### Zip code * Your appointment date * How did you hear about us? * First time wearing lash extensions? * Yes No Do you wear glasses? (if yes, how often do you wear glasses?) * sometimes always no, never Are you allergic to acrylate/cyanoacrylate (bonding agent)? * Yes No Do you have sensitive eyes? * Yes No Frequent eye irritation, watery eyes, and/or itchy eyes? * Yes No I understand and consent to having my eyes closed throughout the procedures. * Yes I consent to having my before and after pictures taken for advertising and marketing purposes. I understand that these pictures may be posted to social media sites. * Yes Yes, but not the entire face No I understand that some irritation, itching or burning may occur on the skin, or risk of irritation to the orbital eye area if come into contact with bonding agent. * Yes I understand that additional conditions could occur or be discovered during/after the procedure which could affect my ability to tolerate the procedure. * Yes Although every precaution will be taken to ensure your safety and well-being before, during, and after your lash extension application, please be aware of the following information and possible risk. *** I understand that if I have any concerns, I will address them with my technician. I give permission to my technician to perform the lash extension procedure we have discussed and will hold him/her and his/her staff harmless and nameless from any liability that may result from this treatment. I have accurately answered the questions above, including all known allergies, prescription drugs, or products I am currently ingesting or using topically. I understand my lash extension specialist will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult the lash extension specialist immediately. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the lash extension specialist, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today. * (Initial) Signature * Thank you!
