Client Information:

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Is this the first time you have had lash extensions applied?
Please indicate if you have worn within the last 60 days any of the following types of lashes:
Do you curl, perm, or tint your lashes?
Are you?
Do you wear contacts?
Do you habitually pull, rub, or pick at your lashes for any reason :
Do you have , or are you being treated for any eye illness or injuries?
What side do you predominatley sleep on?
Do you have allergies?
Are you able to keep your eyes closed and lie still for 2 hours or longer?
Have you had any caffeine in the last 4 hours?
Are you using glycolic acid and or retin-a, retinols ect. (this may cause allergic reactions)
Are you using Latisse, or any brand of lash growth serum?
Please circle any of the following that may apply to you:


I have agreed to have Lash & Brow Envy apply eyelash extensions to and/or removed from my eyelashes. Before my qualified professional can perform this procedure, I understand I must complete this agreement and provide my informed consent by signing and dating where indicated below.

For valuable consideration, in order to have my eyelash extensions applied and/ or removed from my eyelashes:

1. Waiver of Liability: I understand there are risks associated with having artificial eyelashes applied to and/or removed from my exsiting eyelashes, and that notwithstanding the utmost of care in the application or removal of these products,there still exist risks associated with the procedure and product itself, which include without limitation: eye irritation, eye pain, discomfort, and in rare cases, blindness when improperly handled or cared for. As part of this procedure, I understand that a certain amount of eyelash adhesive material may become dislodged during or after the procedure, which may irritate my eyes or require further follow up care, at my own expense to prevent damage to my eyes. I also understand there is more than one technique for applying lash extensions to my eyelashes, and I will not attribute any liablility to the professional of Lash & Brow Envy as a result of the procedure or the use and the care of these lashes. I also agree to defend , indemnify and hold harmless the professional or Lash & Brow Envy from any and all claims, actions, expenses, damages, liabilities, including reasonable attorneys fees which might be asserted against them as a result of my having this procedure performed, or my purchase of these products. As used in this agreement , the terms professional" and Lash & Brow Envy" include all of their respective officers, directors, agents, employees, successors and assigns.

2.Care & Maintenence: I agree to follow the care and maintenence instructions provided by Lash & Brow Envy and/or Professional for the use and care of my lash extensions, and that if any follow up care is required due to my own negligence, or failure to follow these instructions, this will be at my own expense and risk. I understand that if I do any of the following, it may result in damage to my lash extensions or may cause my lashes to fall off prematurely. Knowing this I agree to follow these tips for best results: I will avoid oil based eye products , as these will loosen the bond of my lash extensions. I will avoid getting my lashes wet within the first 24-48 hours of my application. For the first two days after application I will avoid swimming, saunas, and steam rooms. If I experience any itching or irritation I agree to contact my professional immediately to have them removed. I agree to avoid using waterproof mascara and to not use an eyelash curler, perm or tint my extensions. I agree not to pick, rub, or pull on my extensions. I understand that I should not attempt to remove my extensions on my own or with any product, unless by my professional or Lash & Brow Envy.

3.No known medical conditions/lnformed Consent I have read and completed the client intake form in its entirety and in truth. I acknowledge that I have been advised of the potential harmful or negative side effects ( such as premature shedding of my lashes) that the lash extensions procedure or removal may casuse to those who have specific medical or skin conditions. I understand that the adhesives and adhesive remover are a skin, eye and mucus membrane irritant, and that in rare cases persons may be allergic or have hypersensitivity to synthetics, cyanoacrolate, or formaldehyde which in small amount may be present in the adhesive. I understand that the procedure requires that I lay still for up to 2 hours or longer with my eyes shut, and that if I wear contacts, I must remove them for the duration or removal or application.l further state that I have no known medical condition that might be aggrevated by the procedure or any medical condition that would prevent me from complying with or heeding to the Professional and/or Lash & Brow Envy's instructions or these warnings. If any action is brought to enforce the terms of this agreement, the prevailing party shall be entitled to its costs and reasonable attorneys fees. Any claims arising out of this agreement will be resolved through binding arbitration using the rules of the American Arbitration Association. This agreement will remain in effect for this procedure, and all future procedures conducted by the professional of/or Lash & Brow Envy. I agree that this agreement is binding upon me and my heirs, legal representatives and assigns. I represent that I am over 18 years of age and that I have the right to enter this agreement , or if I am under 18 years of age, I have had my parent or legal guardian consent to this agreement, and his or her relationship to me is as follows:

4.Consent of Fill on Other Lashes: I hereby give Lash & Brow Envy full consent to fill my lashes even though I may have gotten a full set somewhere else and/or these lashes do not belong to Lash & Brow Envy. I understand there could/may be an allergic reaction or an allergy due to the mixture of two different glues. I hereby release Lash & Brow Envy of full responsibility of any allergy, allergic reaction or infection. I understand it can cause damage and irritation to the eye. If this occurs I am taking full responsibilty and action to make my eyes healthy again. Lash & Brow Envy has the right to decline removal of the lashes if this occurs.

5.Consent to waive preliminary glue test:

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Professional Use Only Notes:

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