Medical History Form

30 Lashes

Client Agreement and Waiver Form
Full Name*

First NameLast Name
Phone Number*
Email*
example@example.com
Alopecia (loss of hair)Any disease causing twitch ing, shaking or erratic movementsBells past or any condition that makes the eyes open or close properlyBlepharitis (an ocular condition characterized by chronic inflammation of the eyelidChemotherapyClaustrophobiaContact LensesCysts near the eyes or browsDry eye syndromeEye infections such as conjunctivitis or imperialEye infections such as UveitisGlaucomaHay fever/RhinitisHordeola or styesHypersensitive skin/EyesPrevious reactions to collagenKeratitis (iinflammation of the cornea)Post ChemotherapySkin disease, skin trauma, cuts, abrasions, burns, and swellingSkin disorders in the eye or brow areas (Dermatitis, Xanthelasma, and Syringoma)Trichotillomania (impulse control disorder and is the compulsive urge to pull out one's hair)Weak eyelashesWatery eyesNegative reaction to a patch or sensitivity test (allergy. Patch test MUST be done 24-48 hrs before service).
I understand there are risks associated with having beauty enhancement services. Please check all the services you will be receiving or interested in for future appointments:Lash Lift and TintLash LiftLash TintBrow Laminating and TintBrow LaminatingBrow TintHenna BrowLash Extenstions:Classic; orHybridStyles:Natural eye;Open Eye;Whispy;Kitten eye; orReverse Kitten eye (Consultation with the tech can also determine a flattering lash map if you are undecided).I understand the lash extensions will be applied to the natural lash as determined by the technician so as not to create excessive weight on the natural lash, thereby preserving the heath, growth, and desired look of the client's lashes.I understand that as part of any of the above procedures, eye irritation, pain, itching, discomfort and in rare cases, eye infection may occur.I understand and agree that if I experience any of these issues, I will contact my technician and have the extensions removed immediately and consulting a physician at my own expense.I understand that even though the technician may apply and remove the extensions properly, the adhesive material may become dislodged during or after the procedure, which may irritate my eyes or require further follow up care.I understand and agree to follow the aftercare instructions provided by my technician. Failure to follow the aftercare instructions may cause the lash extensions to fall out.I understand that in order for the services to be successful, I will need to keep my eyes closed for the duration of the procedure (approximately 60-180 minutes).I understand that if I am unable to be in a reclined position, which may aggravate any health conditions, I will not be able to have the desired service(s).I understand this agreement will remain in effect for this procedure and all future procedures conducted by my technician or any other technician at 30 Lashes.I understand this agreement is legally binding and that I have read and fully understood all information above.I represent that I am 18 years old or older. If below 18 years old, a parent or legal guardian must also sign the Agreement and Waiver form.I release my 30 Lashes technician from all liabilities associated with this (these) procedures.I understand I have been advised to follow the aftercare protocol from my technician so as to avoid any discomfort or adverse side effects after the procedure has been completed.
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Name*

First NameLast Name
Signature*

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If under the age of 18, a parent or legal guardian must sign and be present at the appointment:

Parent or Legal Guardian First NameLast Name
Signature

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30 Lashes