Lash Services Consent Form

Salon Name: The Babe Spa

Service (please check): ❏Eyelash Extensions ❏Extension Removal ❏Quickset

❏ or ❏ w/ Tint

Client Details

Client Name:______________________________________________ Date of Birth: __________________

Street Address: City: State: Zip Code:______

Home Phone: _________________ Mobile Phone: _______________ Email: ________________________

Sex: ❏M ❏F

How did you hear about us?

❏Internet ❏Hair/Nail Salon ❏Television ❏Magazine ❏Walk by ❏Friend (Specify) ❏Radio ❏Other (Specify)

_______________________________________________________________________________________

Eyelash Design

Wanting to achieve?

❏Longer lashes ❏Darker Lashes ❏Fuller lashes ❏Curlier Lashes

Patch Test

Would you like to have a patch test performed? ❏Yes ❏No ❏Not required (Tech Signature)

_____________

Date performed or Date Waived?______________

Agreement: I request and consent to these procedures being carried out today without undergoing a sensitivity

patch test. The sensitivity test, which if conducted, may indicate my sensitivity/allergy to the products. I

understand the contents of this form and take full responsibility for my actions, thus absolving all other parties

of their responsibilities, if any, associated with the supply of the products and service(s).

Client Signature:_______________________________________ Date:__________________________

Technician Signature:___________________________________ Date:__________________________

Medical History

Current Conditions, Previous Discomfort, Stinging or Adverse Reactions

Please check any that apply.

❏Inflammation of eyelid/eyebrow

area

❏Botox/dermal fillers

❏ Wear Contacts

❏Skin trauma, swelling or

abrasions

❏Skin Disorders/disease

❏Chemotherapy (current cancer

treatment)

❏Recent operations around eye,

head, or face in immediate area

❏Eye infections/conjunctivitis

❏Hypersentive skin

❏Recent tattooing, microblading

or feather touch treatments

❏Recent eye surgery

❏Sunburn

Have you had lash or brow tinting before and experienced a reaction? ❏Yes ❏No

Details____________________________________________________________________________

Have you worn Lash extensions before? Strip Lashes? ❏Yes ❏No

Details____________________________________________________________________________

Allergy & Medical History:

Do you have allergies? ❏Yes ❏No (please specify.) _____________________________________________

Have you had an allergic reaction to hair color? ❏Yes (please specify.) ❏No __________________________

Are you allergic to medical tape? ❏Yes (please specify.) ❏No ❏Unsure _____________________________

Have you had any skin problems in the past 4 weeks? ❏Yes (please specify.) ❏No _____________________

Do you have abnormally sensitive eyes? ❏Yes (please specify.) ❏No

________________________________

Any medications (Prescribed and Over the Counter including vitamins/herbs/supplements) or Skincare

products you are currently using:

________________________________________________________________________________________

Other relevant information: (Any illnesses or conditions you are being treated by a physician for?)

________________________________________________________________________________________

I certify that the medical history provided today is accurate and complete to the best of my knowledge.

Client Signature:_________________________________________ Date:_________________________

Technician Signature:_____________________________________ Date:________________________

General Health and Safety Recommendations

Eyelash Extensions are not for everyone; prior to application you should notify and discuss with your certified

Eyelash Extensionist if you have recently or frequently experienced any of the following:

● Unusual sensitivity or skin reaction to

cyanoacrylate-based adhesives.

● Moderate to severe allergies on combination

with abnormal eye discharge,

● Any eye disease or medical condition, such

as Conjunctivitis (pink eye).

● A compromised immune system due to

cancer treatment, hepatitis, or advanced

AIDS.

● Any type of cancer

● Alopecia

● Skin disease

● Any metabolic or endocrine disorder

● Blunt trauma in or around the eye area.

● Intoxication or impaired motor skills do to

medications, alcohol, or any other drug.

Never allow any uncured cyanoacrylate-based adhesives or removers to contact the eyelid or eyeball. Any

uncured cyanoacrylate-based adhesives or removers in contact with the eyelid or eyeball may cause

temporary or permanent eye damage, including temporary or permanent blurred or loss of vision. For any

reason, if uncured cyanoacrylate-based adhesives or removers contacts the eye area, immediately flush with

large amounts of water. Seek immediate medical attention.

Procedure Consent

Although we take every precaution to ensure your safety and well-being before, during and after your brow

service, please be aware of the possible risks below. Please initial.

________ I understand that tinting lashes or brows have some inherent risk of irritation to the orbital eye area,

including the eye itself, and could result in stinging or burning sensation, blurry vision and potential blindness

should the tint enter into the eye.

________ I understand that eyelash extensions are semi-permanent. I understand that the lasting beauty and

effect are highly variable and dependant upon, among other factors, the skill of the certified eyelash

extensionist, my normal hair growth cycle, my use of cosmetics and skincare products, and my adherence to

the instructions for maintenance and care.

________ I understand that any uncured cyanoacrylate-based adhesives or removers in contact with my eyelid

or eyeball can cause temporary or permanent damage, blurred or loss of vision.

________ I understand that in the case of lash extensions, sleeping on my face, extreme weather changes,

steam, sauna, and other activities may damage the adhesive or crimp the extensions and may require ongoing

maintenance (similar to eyebrow extensions) and that the refill fees are based on time and/ or the number of

extensions that need to be replaced at the refill appointment.

________ I give permission to my certified lash extensionist to perform the procedure we have discussed, and

will hold him/her and his/her staff harmless from any liability that may result from this treatment.

________ I verify that I do not have any condition as noted above, or any other condition, which I am aware,

that would affect the general use or application of the eyelash extensions

________ I understand that in the event I have questions or concerns regarding my treatment, I will consult the

certified lash extensionist and The Babe Spa, LLC. immediately.

I __________________________________________ (printed name) hereby consent to the procedure and

authorize a certified technician working with The Babe Spa, LLC. to apply products to my own lashes.

Client Signature:_________________________________________ Date:_________________________

Company Lateness and Cancellation Policy

Our time is very valuable. To ensure that we can provide all of our clients with excellent service, we ask that

you be on time to all of your appointments. Please arrive at least 5 to 10 minutes prior to your scheduled time

to ensure you receive your full appointment time.

In the event that you should be tardy, we ask that you be considerate and call to inform us of your situation so

we may take necessary action or make special arrangements. Please be aware that if you are 15 minutes or

more late to your appointment, you will be voided. You will need to reschedule. NO EXCEPTIONS.

In the event that you need to cancel or reschedule your appointment, we asked that you notify us at least 48

hours in advance of your scheduled appointment.

● WE RESERVE THE RIGHT: to charge 50% of the scheduled service price when cancelling or

rescheduling less than 48 hours prior to your appointment.

● WE RESERVE THE RIGHT: to charge 100% of the scheduled service(s) on No-Shows.

** ALL CLIENTS MUST HAVE A CREDIT CARD ON FILE PRIOR TO BOOKING AN APPOINTMENT FOR

ANY SERVICE TO GUARANTEE YOUR APPOINTMENT **

The satisfaction of our clients is our main priority. We offer prompt solutions to any problems or concerns that

may occur.

We do not offer refunds, credits, or exchanges for products sold or services rendered.

If, for any reason, you feel dissatisfied with any of our services, please bring this to management’s attention.

We appreciate all feedback, negative or positive, from our clients to better serve you. As part of our service we

like to provide follow-ups by phone and email (contact@thebabespa.com), for any questions or concerns.

I have fully read, understand and acknowledge The Babe Spa, LLC.’s policy regarding lateness and

appointment cancellations.

Client Signature:________________________________________________ Date:__________________

Company Privacy Policy

We value your privacy. We do not disclose your personal information or share it with other outside entities

unless otherwise authorized by you. Your information is used for internal statistic, marketing, or educational

purposes. We do not send spam emails. We only communicate with our clients and potential clients regarding

new services, price changes, special offers, and appointment notifications.

Photo Release Waiver

Client Initials ______ I understand that for legal purposes, The Babe Spa, LLC, will take photos before and

after the service is complete.

Client Initials ______ I hereby grant and authorize The Babe Spa, LLC the right to take, edit, alter, copy,

exhibit, publish, distribute and make use of any and all pictures or video taken of me to be used in and/or for

legally promotional materials including, but not limited to, newsletters, flyers, posters, brochures,

advertisements, fundraising letters, annual reports, press kits and submissions to journalists, websites, social

networking sites, and other print and digital communications, without payment or any other consideration. This

authorization extends to all languages, media, formats and markets known or hereafter devised. This

authorization shall continue indefinitely, unless I otherwise revoke said authorization in writing.

Client Initials ______ I understand and agree that these materials shall become the property of The Babe

Spa, LLC. and will not be returned.

Client Initials ______ I hereby hold harmless, and release The Babe Spa, LLC. from all liability petitions, and

causes of action which I, my heirs, representatives, executors, administrators, or any other persons may make

while acting on my behalf or on the behalf of my estate.

Client Signature:________________________________________________ Date:__________________

I have fully read and understand and hereby acknowledge the contents of this consent form to its entirety

including my responsibilities detailed throughout this document. I have been given the opportunity to ask

questions about the products, application procedure, and any risks or hazards involved. I verify that the

certified lash extensionist has fully explained the procedure and answered any questions to my satisfaction. I

have sufficient information to give consent.

Client Signature:________________________________________________ Date:__________________

Technician Signature:____________________________________________ Date:__________________