Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

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COVID-19 CONSENT *

Below is an overview of what you can expect when you return to The Lash Stop for your appointment. Please complete the following and sign below. Symptoms of COVID-19 include: Fever Cough Shortness of breath or difficulty breathing Chills Headache Sore throat New loss of taste or smell Nausea or vomiting I understand the above symptoms and affirm that I, as well as all household members, DO NOT currently have, nor have experienced the symptoms listed above within the past 14 days.

Affirm/Check

COVID-19 CONSENT *

I affirm that I, as well as all household members, have NOT been diagnosed with COVID-19 within the last 14 days.

Affirm/Check

COVID-19 CONSENT *

I affirm that I, as well as all household members, have NOT knowingly been exposed to anyone diagnosed with COVID-19 within the last 14 days.

Affirm/Check

COVID-19 CONSENT *

I understand that The Lash Stop and personnel cannot be held liable for any exposure to the virus or any other contagion caused by misinformation on this form or history provided by each client.

Affirm/Check

APPLICATION/CONSENT *

I understand that in rare occasions there are risks associated with having artificial eyelashes and eyelash extensions applied to or removed from my natural eyelashes. I further understand that in rare cases as part of the procedure eye irritation and discomfort could occur. I agree that if I experience any of these conditions with my lashes that I will contact the certified eyelash extension professional that performed this procedure and it may be beneficial to have the eyelashes removed.

Affirm/Check

APPLICATION/CONSENT *

I understand and consent to having my eyes closed and covered for the duration of approximately 60-150 minute procedure. Times may vary depending on the type and number of eyelashes applied.

Affirm/Check

APPLICATION/CONSENT *

I understand and agree to the after-care instructions provided by the certified eyelash extension professional for the use and care of my eyelash extensions. I realize and accept the consequences of failure to adhere to these instructions may cause the eyelash extensions to fall out and/or decrease the time the lashes will last.

Affirm/Check

APPLICATION/CONSENT *

I am informing the certified eyelash extension professional of the following conditions by marking with a check:

Current use of contact lenses which I may be asked to remove during the procedure

Current use of anything such as oil-containing sunscreen or moisturizers around the eyes

Current use of eye drops of any kind, prescription or over-the-counter

Current allergies or sensitivities

History of recurrent eye or tear duct infections

History of dry eyes or Sjorgen’s Syndrome

Recent history of Chemotherapy

Other medical conditions which would prohibit or compromise placement and retention of eyelash extensions

NONE

APPLICATION/CONSENT *

I agree to the following eyelash extension follow-up and maintenance instructions: Check ALL

No waterproof mascara 48 hours prior to appointment as this will effect retention.

No oil based products around the eye area

No water can come in contact with the eye area for 24 hours after the application

No tinting or perming of eyelash extensions 60-90 days before application

No tinting or perming of eyelash extensions after application (within 60+ days may vary due to aftercare)

No pulling or rubbing of the eyelash extensions

Should any kind of eye drops be necessary, extra care should be taken to prevent moisture from coming into contact with the eyelash extensions

Maintain cleanliness, keep eyelash extensions clean with The Lash Stop's Lash Bath wash, or eyelash wash.

APPLICATION/CONSENT *

This agreement will remain in effect for this procedure and all future follow-ups conducted by the certified eyelash extension professional.

Affirm/Check

APPLICATION/CONSENT *

I read English and understand that this consent agreement is legal and binding. I have read and fully understand all information in this agreement. I am over 18 years of age and consent to the agreement and to the eyelash extension application procedure.

Affirm/Check

Date *

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