Forms

CLIENT CONSULTATION

Name *

First

Last

Email *

Please enter your email, so we can follow up with you.

If I had a magic wand- What would you change about appearance? *

What would you change about your life style? *

What services are you interested in? *

Have you tried this before?

Yes
No
I dont know

Describe your perfect experience:

Are you allergic to anything? *

Contraindications – Check all that apply

Pacemaker
Clausterphobia
Cancer Remission or active in the last 3 years
Injections in the past 2 months
Pregnancy
Other- please list under allergies if there is anything not listed we should be aware of.

Consent *

I understand that if I have any concerns, I will address these with my stylist. I give permission to my stylist to perform all procedures we 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 stylist 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 stylist 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 stylist responsible, which may be affected by the treatment performed today. I understand there is a strict $40 late/no show policy.

Phone

LASH EXTENSION CONSENT

Texas Beauty Rehab's Lash Consent

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 risks. *

I understand & agree

A full set of lash extensions can make the appearance of my own lashes about 30-300% thicker, and make my lashes appear 20-50% longer. *

I understand and agree

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 and agree

Some irritation, itching or burning may occur on the skin if the bonding agent comes into contact with it. *

I understand and agree

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 and agree

This is a semi-permanent procedure, as my natural lashes will continue to grow and fall out (2-5 shed naturally daily), making touch-up or “fill” appointments necessary to maintain the original look achieved by replacing the lashes that have fallen out. The rate of growth and how well I personally maintain them will depend how long they last. Fills can be done weekly for continuous max volume. Bi weekly to maintain regular volume. Monthly when they get very sparse. *

I understand and agree

Additional conditions could occur or be discovered during the procedure or activities/situations/environments/other could arise from my lifestyle outside of Texas Beauty Rehab which could affect my ability to tolerate the procedure. *

I understand and agree

If my lashes ever feel stuck, itchy or feel any discomfort or problems arise I will contact Texas Beauty Rehab for a 10 minute free appointment to correct this problem immediately. *

I understand and agree

Though 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 and agree

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

I understand and agree

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 understand and agree

Name *

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