Name *
You must be 18 years of age or older to receive this procedure.
Phone *
Health History *
By submitting this form I have requested and do hereby authorize A Lash Above The Rest to perform either an eyelash extension removal and/or application, a temporary placement of synthetic eyelashes to my own natural lashes to enhance the appearance of my face and/or skin which may necessitate the use of prescriptions or medical care provided by a physician. I understand the process of this procedure requires individual synthetic eyelashes to be glued to my own natural lashes. Some severe cases may result in complications and may risk allergic reaction to the adhesive used to apply the lashes. In addition, I understand that through normal use, the lash extensions need to be maintained on a regular basis and there is no guarantee for the length of the time that the extensions will stay adhered. Abnormal use includes, but is not limited to, use of waterproof mascara, excessive rubbing, excessive swimming, sauna, steam rooms, pulling on lashes or use of oil-based cosmetics and makeup removers, and use of eyelash curlers or crimping the lashes in any way. I understand a follow up appointment is recommended within 2-3 weeks of the initial service. I further understand that the clinical outcome for any of the above described procedures is in direct pathology to the nature of my skin pathology and condition. All conditions must be revealed or disclosed by me to A Lash Above The Rest regarding my health history, medications being taken and any past reactions to products used including medications, as well as a prior cyanoacrylate adhesive reaction. Additional conditions could be discovered during the service, which could affect my ability to tolerate the procedure. I understand it is my responsibility to not move excessively or suddenly during the application or removal and to keep my eyes closed during the entire process application or removal and to keep my eyes closed during the entire process unless otherwise directed. For those who have special conditions or have never had a procedure of this nature, a patch test is advised. I understand the nature, purpose, and the risk of these procedures. I am aware of the cost of the services and understand, I will need a touch-up. Touch0-ups are done for an additional nominal fee. I certify that I have consulted with A Lash Above the Rest and have read all applicable literature given to me. The risk of this cosmetic service I have chosen have been disclosed to me. I have read and fully understand all of the informing presented in this consent and release form. I accept the explanation of potential complications and risk described herein. I accept full responsibility, financially, medically or otherwise for any compilations which may arise or result during or following the eyelash extension procedure(s), which are to be performed at my request. I certify that I am 18 years of age or older and am fully capable of executing this consent and release for myself.
Cancellation Policy or No-Show We ask that you please reschedule or cancel at least 2 days before the beginning of your appointment or you may be charged a cancellation fee of 100% of the cost of your service.
Date *
By typing my name, I certify that the information provided is true and I agree to the cancellation policy.