Lashes - Arch Brow Bar

Name *

Date of Birth *

Address *

Address Line 1

City

State

Zip Code

Mobile Phone *

Alternative Phone

Email *

Text Alerts? *

Yes
No

Email Alerts? *

Yes
No

Emergency Contact *

Emergency Contact Phone *

How did you hear about us?

Referred By

What is your current skincare regimen? *

No attention
Some attention
Lots of attention

Skincare Regime Comments

Have you ever received eyelash extensions? *

Yes
No

Have you ever received keratin lash lift? *

Yes
No

Are you pregnant or nursing? *

Yes
No

Do you wear daily disposable, extended wear contacts? *

Yes
No

Have you had any eye surgery, wounds or infections in the last 4 weeks? *

Yes
No

Have you undergone chemotherapy in the past 3 months? *

Yes
No

Please list all current medications: *

List all allergies to cosmetics or adhesives: *

Waiver and Release

I authorize all trained and certified lash specialists at Arch Brow Bar to perform professional eyelash treatments such as eyelash extensions and/or keratin lash lift. I understand eyelash extensions require individual synthetic eyelashes to be adhered with professional eyelash glue to my own natural lashes. I understand that it is my responsibility to remain still during the application and to keep my eyes closed during the entire process until otherwise advised by my lash stylist. To perform the keratin lash lift I understand this procedure requires my lashes to be gently adhered to a silicone pad with a watersoluble adhesive and lifted on that silicone pad with a curling agent, a conditioning agent and nourishing oil. I understand it is my responsibility to be still during the procedure and to keep my eyes closed during the process unless otherwise advised by my lash stylist. I have been given pre-treatment and post-treatment forms for both lash services. I am already aware of the known risks of these cosmetic procedures and understand some cases could result in unexpected complications. Complications include transient eye, redness and irritation, allergic reaction to the adhesive, under eye gel patches or any of the products used. If at any time I am uncomfortable with the eyelash extension procedure, I will inform the stylist and she will proceed accordingly to satisfy my request, including ending the session if I wish. If the stylist is uncomfortable applying lash extensions on me, she will discuss her concerns with me and may end the session if necessary. I acknowledge I am consenting to these procedures at my own risk and I have disclosed on any and all forms presented to me all conditions and circumstances regarding my health, health history, medications being taken, and any past reactions to products used or medications taken. Additional conditions may occur or be discovered during or after the service, which could affect my ability to tolerate the procedure in its entirety. Should any named or unnamed complications arise I, as herein signed, release my certified lash specialists at Arch Brow Bar from any claims or damages of any nature. I understand this document is a waiver for any and all complications or damages and I cannot and will not hold my lash stylist or Arch Brow Bar accountable. I understand that I am responsible should I require any medical treatment I may need to receive as a result of getting any one of the named eyelash procedures. I accept full responsibility for these and any other complications, which may arise or result during or following the eyelash extension procedure and Keratin lash lift procedures, which are to be performed at my request. I, the client herein signed, certify that I have read and fully understand the above Waiver and Release Form. I certify that I have consulted with a certified lash specialists at Arch Brow Bar. I accept the explanation of potential complications and risks described herein. I certify I am of sound mind, and I am fully capable of executing this waiver and release form for myself. I, the undersigned client, acknowledge and fully understand there could be other unknown risks not reasonably foreseeable at this time. I, the client herein signed, for the purposes of documentation, and advertising, hereby consent to “before and after” photographs should my lash stylist ask for them.

Date *

Signature *

By signing above, I certify that I have read and fully understand the contents of this consent form, and the information I provided are complete, accurate, and up to date to my knowledge. All personal information will be kept confidential.