Client Consent Form

EYELASH EXTENSION

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Type of Service

CONSENT AND RELEASE AGREEMENT FOR

EYELASH EXTENSION

  PLEASE READ AND CHECK ALL LINES

PLEASE NOTIFY YOUR TECHNICIAN BELOW OF ANY QUESTIONS OR CONCERNS REGARDING YOUR PROCEDURE OR IF ANY OF THE BELOW SCENARIOS APPLY TO YOU OR ANY MEDICAL CONDITIONS.

I acknowledge I am age 18 or older.

I understand that after my service, there will be no refunds. No exceptions.

I understand that a full set of lash extensions can make the appearance of my own lashes about 30-50% thicker, and make my lashes appear 20-50% longer.

I understand that lash extension services have some inherent risk of irritation to the orbital eye area, including the eye itself, and could result in stinging and burning, blurry vision and potential blindness should the adhesive enter the eye or should an allergic reaction occur.

I understand that some irritation, itching or burning may occur on the skin if the bonding agent comes into contact with it.

I understand that if the bonding agent comes into contact with my eye, my eye will be flushed with water and I will be assisted in seeking medical attention immediately.

I understand that this is a semi-permanent procedure, as my natural lashes will continue to grow and fall out normally, making touch-up or “fill” appointments necessary to maintain the original look achieved by replacing the lashes that have fallen out. Most clients require a fill appointment every 2-3 weeks.

I understand that while every attempt will be made to provide me with the length and fullness I have chosen, my final result may not be what I initially envisioned.

I understand that it is imperative that I disclose all of the information requested in the Client Profile/Health History.

I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications.

I consent to “before and after” photographs for the purpose of documentation, potential advertising and promotional purposes.

If I have any signs and symptoms of infections I will seek medical care. These include but are not limited to: redness, swelling, tenderness of the procedure site, red streak going from procedure site towards the heart, elevated temperature, or purulent drainage from the procedure site.

I grant permission to TN-Beauty, Thunyatorn LLC, Thai Serenity Spa to take and use: photographs and/or digital images of me for use in news releases, educational materials and/or social media platforms including but not limited to Instagram, Facebook, and Pinterest. If no photo please inform your your artist.

If a dispute arises out of or relates to this contract, or the alleged breach thereof, and if the dispute is not settled through negotiation, the parties agree first to try in good faith to settle the dispute by mediation within 30 days administered under (name Rules) before resorting to arbitration, litigation, or some other dispute resolution procedure. In the event that parties are unable to agree on a mediator, a mediator shall be appointed by the named administrator. The process shall be confidential based on terms acceptable to the mediator and/or mediation service provider.

I acknowledge it is not reasonably possible for my technician to determine whether I might have an ALLERGIC reaction to the products used in this process. I agree to forego a patch test and accept the risk that such reaction is possible.

Notice that eyelash extension products have not been approved by the federal Food and Drug Administration and that the health consequences of using these products are unknown.

I have read all the Precare guidelines and acknowledge that Aftercare instructions are available on www.TN-Beauty.com. I agree to follow them to the best of my ability. I agree that any touch up work needed, due to my negligence will be done at my own expense.

I understand the restrictions on physical activities such as bathing, sauna, recreational water activities, gardening, or contact with animals, and the duration of the restrictions.

I understand that if I have any concerns, I will address these with my lash extension specialist. I give permission to my lash extension specialist 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. I certify that I have read or have had read to me the contents of this whole form. I understand the risks and alternatives involved in this procedure(s) and I have had the opportunity to ask questions and all of my questions have been answered. I acknowledge that I have reviewed and approved the material given to me.

Special requests, concerns, remarks or note to technician:

Consent to Treat a Minor:

By my signature below, I hereby authorize technician to administer services to my child or dependents. 

Please let us know if you would you like to receive a copy of this statement and consent.

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