Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone *How did you hear about us?Is this your first time having lash extensions applied?YESNODo you wear contact lenses?YESNODo you have, or are you being treated for any eye illness or injury?YESNOWhat side do you predominately sleep on?LeftRightAre you able to keep your eyes closed and lie still for up to 2 hours or longer?YESNOPlease check off any of the following that might apply to you: Allergy to adhesives band aid or medical tapeAllergy to surgical glue or nail glueSeasonal allergiesEye illness or injuryBlepharitis (inflamed eyelids)Permanent eye-makeupEye liftDrugs that can cause temporary hair lossMajor surgery within last 120 daysLasik Eye Surgery Allergy to GlycerinOtherPlease Agree to the terms and conditions I hereby agree to have eyelash extensions applied to my natural lashes and consent to the placement and/or removal of the eyelash extensions by the certified professional.I understand that because of the natural lash cycle and wear and tear, I will need to maintain my extensions with touch up appointments usually recommended about every 2 to 3 weeks to keep them full.I hereby grant to permission to Air of Earth Aesthetics the full right to take, publish and reproduce photographs ofme, my face, my eyes and/or eyelashes, both before and after this procedure, for any advertising, education, or other purposes whatsoever, includingthe right to retouch these photographs as deemed necessary by Air of Earth Aesthetics. I further expressly assign any copyright in thesephotographs to Air of Earth Aesthetics. I also grant my consent forAir of Earth Aesthetics to use my image and likeness as contained in thesephotographs for any advertising or other purposes, along with any comments I may provide. I agree to follow the care and maintenance instructions provided by my lash tech for the use andcare of my Lashes, and that if any follow up care is required due to my own mistake or negligence, or failure to follow these instructions, thiswill be at my own expense and risk. I understand that if I do any of the following, it may result in damage to my lashes, or may cause my lashesto 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 Lashes. I will avoid getting my lashes wet within the first 24 hours after my application. For the first two days after application I understand it isbest to avoid swimming, saunas or steam rooms. If I experience any itching or irritation, I agree to contact my Lash Tech Professional immediatelyto have the lash extensions removed. I agree to avoid using waterproof mascara and to not use an eyelash curler, perm, or tint my Lashes. Iagree to not pick, pull or rub my Lashes I understand that I should not attempt to remove my lash extensions on my own or with any product,but that the procedure requires that my lash extensions be professionally removed.No Known Medical Conditions / Informed Consent. I have read and completed the Client Intake Form in its entirety and intruth. I acknowledge that I have been advised of the potential harmful or negative side effects (such as the premature shedding of my eyelash) thatthe lash extension procedure or removal may cause to those who have specific medical or skin conditions. I understand that the adhesives andadhesive 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 upto 2 hours or longer with my eyes shut, and that if I wear contacts, I must remove my contact lenses for the duration of the lash extension applicationor removal. I further state that I have no known medical condition that might be aggravated by the procedure or any medical condition that wouldprevent me from complying with or heeding to the professional’s instructions or these warnings. Please type your signature belowDatePhoneSubmit
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