Lash Service Consent Form Date of Birth * MM DD YYYY Name * First Name Last Name Mobile Phone * (###) ### #### Email * How were you referred to Angelica B Beauty? (i.e., friend [name, please], Facebook or other social media site, other website, etc?) I understand that some risk of this procedure may be, but not limited to eye redness and irritation due to the vapors and fumes fumes from the adhesive.: Yes or No * Yes No I understand that it is my responsibility to keep my eyes closed and be still during the entire procedures, until my lash artist addresses me to open my eyes.: Yes or No * Yes No I understand that this procedure require single synthetic eyelashes to be adhered to my own natural eyelashes.: Yes or No * Yes No I agree to disclose any allergies or other topics my lash artist should be aware of.: Yes or No * Yes No I agree that by reading and signing this consent form, I release from any claims or damages of any nature. Yes or No * Yes No I agree that I have read and fully understand this entire consent in its entirety, and have answered everything to the best of my ability. I have informed of potentially harmful and negative side effects that could be caused by the application and/or removal: Yes or No * Yes No I confirm and agree that I wish to engage in the service of having eyelash extensions applied.: Yes or No * Yes No -I understand that some risk of this procedure may be, but not limited to eye redness and irritation due to the lifting solution ( only initial if receiving a lash lift ) -I understand that this procedure requires a lifting solution and or color tint near or around my lashes and eye ( only initial if receiving a lash lift) Consent I understand, have read, and have fully completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. While all treatments are recommended to achieve the best possible results, I do understand that not all treatments will have the same results on every client; therefore no guarantee can be given. I also understand that withholding information or providing misinformation may result in contraindications and / or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the technician of any of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release Angelica B Beauty from liability and assume full responsibility thereof. Consent is valid for one year. If any changes do occur please make sure and inform your Esthetician. Required * I accept I decline Full Legal Name * First Name Last Name Thank you!