Ai-Lashes Eyelash ServiceIntake & Consent FormPlease complete the following form completely and accurately. Your information will be kept confidential. Name * First Name Last Name Email * Phone (###) ### #### How did you hear about us? Website /QR code Google Search Social Media Friend Other Have you ever had eyelash extensions before Yes No Within the past 60 days, have you tried any of these lash styles? Individual Strip Flare / Cluster Other None Lash style preference Lash style preference Classic Hybrid Volume Mega Volume Do you do any of the following? Curl Perm Tint Nothing Are you able to lay still with your eyes closed for 2 hours? * Yes No Medical History Procedures Lasik Eye Surgery Permanent Eye Make Up Blepharoplasty (Eye Lift) Contact Lenses ( may need to remove during procedure) Is there Anything else we should know? Eye illnes Blepharitis Conjunctivitis / Pink Eye Allergies Latex Lash Tape Adhesive / Glue Glycerin Other Waiver Acknowledgement This waiver is executed on the date of submission, who acknowledges and agrees to the following terms regarding the eyelash extension services provided by Ai-Lashes: Acknowledgment of Risks I understand that the application and removal of eyelash extensions involve inherent risks, including but not limited to allergic reactions, eye irritation, or damage to my natural lashes. I acknowledge that these risks exist despite any precautions taken by the technician or business. Release of Liability I hereby waive, release, and discharge Ai-Lashes , its technicians, employees, and agents from any and all liability for any damages, injuries, or complications (including allergic reactions) that may occur as a result of the eyelash extension services provided. I agree that the technician and business shall not be held liable for any adverse outcomes arising from this procedure. Certification of Information I certify that all information provided by me on this form is true and correct to the best of my knowledge. Consent to Receive Services I understand the nature of the eyelash extension procedure and voluntarily consent to receive the services. I have had the opportunity to ask questions regarding the procedure, and all of my questions have been answered to my satisfaction. After-Care Instructions I acknowledge that I have been informed of, and agree to follow, the after-care instructions provided by the technician. I understand that failure to adhere to these instructions may result in unexpected complications, and I accept full responsibility for any such outcomes. Assumption of Risk By submitting this form, I voluntarily assume all risks associated with the procedure and agree that my participation is at my own risk. I have read and fully understand the above Waiver and Release of Liability. I agree to be bound by its terms. Agree I hereby authorize the technicians to use my before and after photos/videos for business purposes. I further confirm that all of my questions and concerns have been fully addressed prior to the commencement of service. Yes No Time Hour Minute Second AM PM Date MM DD YYYY Thank you!
