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Customer Consent Form
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Client Information
Layout
Name
*
Date of Birth
Age
Race
Occupation
Phone
Address
Email
Visit Outlet
Bangsar Telawi
Bangsar Shopping Centre
Pavilion Bukit Jalil
Setia City Mall
IOI City Mall
Mytown Shopping Centre
Publika Shopping Gallery
How did you hear about us?
*
Website
Magazine
Google / Social Medias
Friends
Others
Others
Is this your first time you have / had eyelash extensions?
*
Yes
No
Do you
*
Curl
Perm
Tint your lashes
No
Are you having your lash extensions applied for
*
a special occasion
daily wear
Do you habitually rub, pull or pick your lashes for any reason?
*
Yes
No
Do you have or are you being treated for any eye illness or injury?
*
Yes
No
Are you able to keep your eye's closed and lie still for up to 2 hours or longer?
*
Yes
No
Please check off any of the following that might apply to you
Lash Eye Surgery
Permanent Eye Make Up
Blepharoplasty (Eye Lift)
Allergies to adhesives or synthetics
Hypersensitivity to cyanoacrylate or formaldehyde or certain adhesives / glues
Major surgery within the last 120 days
Chemotherapeutic agents used in cancer treatment
Client Notes
Layout
Curl
Style
Lash Stylist
Layout
Name
*
Date
*
Lifestyle
Conservation
Sensitivity
Glue Type
Layout
Inner corner length
Middle (center) length
Outer corner length
Layout
Thickness
Lash Length
I agree to the following
*
Please tick the box to agree.
I understand there are risks associated with having artificial eyelashes applied to and / or removed from my natural eyelashes. I understand that the eyelash extensions will be applied to the natural lash as determined by the technician so as not to create excessive weight on the natural eyelash thereby preserving the health, growth, and natural look of the client's natural eyelashes. I understand as part of the procedure eye irritation, eye pain, eye itching, discomfort and in rare cases eye infection may occur. I understand and agree that if I experience any of these issues with my lashes that I will contact my technician and have to remove eyelashes immediately and consult a physician at my own expense. I understand that even though my technician may apply and remove the eyelash properly, that adhesive materials may become dislodged during or after the procedure. I understand and agree to follow the after care instructions provided by the technician. Failure to follow the after care instructions can cause the eyelash to fall off. I understand in order to have the eyelash extensions applied to my eyelashes I will need to keep my eye closes for 60-100 minutes during the procedure. I also need to understand that I will be lying down on a reclined position. This agreement will remain in effect of the procedure and all future procedures conducted by my technician from one year from the date of this form is signed. I understand that this agreement is binding and that I have read and understand all the information listed above.
Layout
Client (Printed Name)
*
Client Signature
*
Clear Signature
Layout (copy)
Parent of guardian (if under 18 years old)
Signature
Clear Signature
Submit