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[Kanata] Eyelash extension form
this is consent form for eyelash extension
Eyelash Extensions Consent - Personal Information section
Name
(Required)
First
Last
Phone
(Required)
Date of Birth (for Birthday promotion)
MM slash DD slash YYYY
Email
(Required)
Address
Street Address
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Consent section
I understand that there are risks associated with having artificial eyelashes applied to and/or removed from my natural lashes
(Required)
I agree
I understand that the eyelash Extensions will be applied to the natural lash as determined by the technician so as not to create Excessive weight on the natural eyelash thereby preserving the health, growth and natural look of the client’s natural eyelashes.
(Required)
I agree
I understand that as part of the procedure eye irritation, pain, itching discomfort and in rare case eye infection may occur.
(Required)
I agree
I understand and agree that if I experiences any of these issues with my lashes, I will contact Beauty Time Centre Inc as soon as possible and have them removed immediately and consult a physician at my own expense.
(Required)
I agree
I understand that even though the technician may apply and remove the eyelash extensions properly, that adhesive material may become dislodged during or after the procedure, which may irritate my eye or required further follow up care.
(Required)
I agree
I understand and agree to follow the after instructions provided by Beauty Time Centre Inc. Failure to follow the aftercare instructions may cause the eyelash extensions to fall out.
(Required)
I agree
I understand that in order to have the eyelash extensions applied to my eyelash I will need to keep my eyes closed for duration of 60-180 minutes during the procedure. I also understand that I will need to be laying in a reclined position. Any medical conditions that might be aggravated by laying still for prolonged period of time may mean that I will not be able to have the procedure performed on my eyes.
(Required)
I agree
This agreement will remain in effect for this procedure and all future procedures conducted by my technician or any other technician conducting business at Beauty Time Centre Inc. I understand that this agreement is binding and that I have read and fully understand all information above. I represent that I am over the age of 18 years. If below 18 years of age a parent or guardian must also sign this consent form.
(Required)
I agree
I release my technician conducting business at Beauty Time Centre Inc from all liability associated with this procedure. There are no guarantees for the bonding time length of the eyelash extensions. Our company or salon is not responsible for any technician errors. I understand that I have been advised to follow the aftercare protocol from my technician so as to avoid any discomfort or adverse side effects after the procedure has been completed.
(Required)
I agree
Signature
(Required)
By signing below, I verify that I have read and understand the above statements and agree to them.
Signature Date
(Required)
MM slash DD slash YYYY
Medical information section
Allergy to adhesives (glues, tapes, band aids)
(Required)
Eyelash extension uses tape, glues and gel pads that may cause a reaction
NO
YES
Other
Chemotherapy treatments within the last 6 months
(Required)
The medication for chemotherapy may cause a reaction to the materials use for eyelash extensions
NO
YES
Thyroid medication
(Required)
Eyelash extensions will not last due to the medication in the system
NO
YES
Lasik surgery or blepharoplasty within the last 6 months
(Required)
Eyes may have sensitivity to eyelash extensions and products used for prepping the eye area (glue, gel pads)
NO
YES
Use of eyelash growth serums/conditioners
(Required)
Can contain ingredients such as glycerin, oil) that my interfere & affect the glue and it bonding power. It is suggested to discontinue use of any growth product prior to application of eyelash extensions
NO
YES
Contact lenses
(Required)
Glue used to apply the eyelash extensions may get underneath the contact lens and can cause abrasion or scratching. Contact must be removed prior to eyelash extension application
NO
YES
Extremely oily skin and hair
(Required)
Natural oils can break down the adhesives used to bond the eyelash extensions causing them to fall out
NO
YES
Client Signature
(Required)
The Information I have given on this form is correct. I have not misrepresented myself nor have I withheld any medical information, surgical state or condition.
Signature Date
(Required)
MM slash DD slash YYYY
May we( Beauty Time Centre inc) take your photo?
(Required)
YES
NO
Photo and Video Consent section
PHOTO/VIDEO CONSENT
(Required)
I, the undersigned, give my irrevocable permission to Beauty Time Centre Inc., (BTCI), and/or
parties designated by BTCI, to photograph/video me and use such photograph(s)/video(s) in any
form of media, for any and all promotional/marketing purposes including advertising, display,
audiovisual or exhibition.
I acknowledge that these images may be used on various platforms owned, controlled by, or
associated with BTCI, including social media, the internet, print and any other suitable medium.
I further consent to the use of my name in connection with the photograph(s)/video(s) if needed
by BTCI and/or parties designated by BTCI.
I understand and agree that I will not receive any payment or compensation for my time or
expenses or any royalty for the publication of the photograph(s)/video(s) or the use of my name
and I hereby release BTCI and/or any parties designated by BTCI from any such claims.
My consent and release shall be binding on me and my estate.
I certify that I have read and fully understand this consent and release, and that all questions
pertaining to this consent have been answered to my satisfaction.
I agree to the photo and/or video policy.
Name
(Required)
First
Last
Date
(Required)
MM slash DD slash YYYY
Signature
(Required)
Parent or Guardian (if Client is under 18 years of age) Name & signature
Parent or Guardian Name
First
Last
Signature Date
MM slash DD slash YYYY
Parent or guardian Signature
Recptionist/Technician section
Receptionist/Technician Name
(Required)
First
Last
Signature date
(Required)
MM slash DD slash YYYY
Receptionist/Technician Signature
(Required)
84738
