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Have you ever had eyelash extensions applied to your natural eyelashes? If so, have you ever experienced an adverse reaction to them?
Have you ever had eyelash extensions removed?
Have you ever had an eyelash lift?
Have you ever used under-eye gel patches?
Do you wear glasses or contacts?
Do you have the tendency to rub your eyes or pull on your eyelashes?
Do you go tanning in a tanning bed or get spray tans?
Are you pregnant, or do you believe you may be pregnant?
Do you have allergies to adhesives or band-aids?
Do you have acrylic or cyanoacrylate allergies?
Have you worn acrylic nails and had a reaction?
Do you have allergies to latex or rubber?
Do you get cysts on your face or near your eyes, eye infections or have eye inflammation?
Do you commonly get blepharitis?
Do you get styes or abscesses on your eyelids, or experience any puss on or around your eyes?
Have you recently had chemotherapy?
Do you hypersensitive skin?
Do your eyes water frequently?
Do you have any eye conditions that make closing your eyes difficult?
Have you worn rubber or latex gloves and had a reaction?
Do you have any other allergies, including those that affect your eyes, skin, or respiratory system?
Do you have allergies to cosmetics or facial product ingredients?
Have you had an eye infection or surgery in the past 6-8 weeks?
Have you had permanent eye makeup applied in the past 6-8 weeks?
Are you currently using or have you previously used Retin-A or Accutane?
Do you have a history of any type of eye disease, condition, or injury that caused you to have hair/eyelash growth or loss?
Have you noticed your hair growth cycle is slower or faster than others?
Are you on any medications including birth control or fertility drugs?
Is there anything else that you think we should be aware of?
Waiver and Release of Liability
The individual named below (referred to as “I,” “me,” or “Client”) hereby authorizes The Lash Den Inc., a California corporation with offices located at 13455 Ventura Boulevard, Suite 220, Sherman Oaks, CA 91423 (“The Lash Den”) to adhere semi-permanent lashes or perform a lash lift on my natural eyelashes (the “Procedure”). I understand it is my responsibility to keep my eyes closed and to lie still during the entire Procedure, or as otherwise advised by the lash technician. I have been fully informed as to the methods and procedures concerning the semi-permanent cosmetic procedure. The risks of the Procedure have been disclosed to me, and may result in complications such as eye redness, irritation, or an allergic reaction. If at any time during the Procedure I am uncomfortable, I agree to inform the technician and understand that they will take reasonable measures to rectify the problem, which may include terminating the Procedure. There have been no guarantees, warranties, promises, commitments, or other statements as to the results of the Procedure made to me, and I acknowledge that I am not relying on any representation or guarantee made by The Lash Den in electing to purchase the Procedure, and I am consenting to have the Procedure done by The Lash Den at my own risk. I confirm that I am in good health, in proper physical condition, and do not have any medical or other condition that would impair my ability to participate in the Procedure, and I have disclosed on the Client Information and History form all conditions and circumstances regarding my health and health history, medications being taken, and any past reactions to products used. I understand that additional conditions may occur or be discovered during the Procedure, which could affect my ability to tolerate the Procedure.
I understand the duration of my eyelash extensions or lash lift requires my careful maintenance. I understand it is critical not to disturb the drying process of the adhesive, especially during the 24-hour period following my Procedure. I agree to wear only water-based eyeliner and mascara, if any, during the eight-week period following my lash appointment. I will not go to a tanning bed, sauna, steam room, or receive a facial within 24 hours of my Procedure. I understand that excessive heat, swimming, use of saunas and steam rooms, use of oil-based eye makeup removers or other products applied to my face should be avoided on or around my eyelashes after my Procedure. Use of mechanical eyelash curlers and crimping eyelashes in any way should be avoided at all times during the eight-week period following my Procedure.
I am aware and understand that any Procedure I have The Lash Den perform for me involves risk of injury and disability. I am also aware of the contagious nature of bacterial and viral diseases, including the 2019 novel coronavirus disease (“COVID-19”), and the risk that I may be exposed to or contract COVID-19 by engaging The Lash Den to perform the Procedure, which may result in illness, injury, disability, or death. I acknowledge that these risks may result from or be compounded by the actions of The Lash Den, its technicians, or others, including their negligent actions. I understand that, while The Lash Den has implemented measures to reduce the risk of injury from the Procedure and the spread of COVID-19, The Lash Den cannot guarantee that I will not be injured, or become infected with COVID-19 due to my participation in the Procedure, and that engaging in the Procedure may increase my risk of contracting COVID-19. Notwithstanding these risks, I acknowledge that I am voluntarily participating in the Procedure with the knowledge of the risks involved. I hereby agree to accept and assume all risks of injury, illness, disability, and death arising from the Procedure, including the risks associated with contracting COVID-19, whether caused by the ordinary negligence of The Lash Den or otherwise. Further, I agree that, by attending my Procedure, I have not, for the past 14 days, had any fever, cough, shortness of breath, loss of taste or smell, or exhibited any other symptoms of COVID-19 (“COVID-19 Symptoms”); I have not tested positive for COVID-19; and I have not been in close contact with anyone who has tested positive for COVID-19 or who is otherwise exhibiting COVID-19 Symptoms, including anyone in my household.
I hereby expressly waive and release any and all claims, now known or hereafter known, against The Lash Den, and its officers, directors, managers, employees, agents, affiliates, personnel, successors and assigns (“Representatives”), on account of injury, illness, disability or death attributable to my participation in the Procedure, whether arising out of the ordinary negligence of The Lash Den, its Representatives, or otherwise. I promise not to make or bring any such claim against The Lash Den or its Representatives, and forever release and discharge The Lash Den and Representatives from liability under such claims. This waiver and release does not extend to claims for willful misconduct, or any other liabilities that California law does not permit to be released by agreement.
I agree that, in the event of any controversy or claim arising out of or relating to the Procedure, such controversy or claim will be determined by binding arbitration in Los Angeles County, California, before one arbitrator, and administered by JAMS. I agree that in the event a decision is determined in favor of one party or another, the prevailing party shall be responsible to reasonable attorney fees and costs incurred in connection with the claim or controversy. I further agree to hold The Lash Den or my technician at The Lash Den harmless from all damages.
I certify that I have read and had explained to me and fully understand the above waiver and release form. I certify that I have consulted with my technician at The Lash Den and have read all applicable literature given to me. I accept the explanation of potential complications and risks described herein. I certify that I am of sound mind, and I am fully capable of executing the waiver and release form of myself. I acknowledge and understand that there might be unknown risks not reasonably foreseeable at this time. I consent to “before and after” photographs to be taken, which may or may not be used for advertising purposes.
I understand that The Lash Den has a 48-hour cancellation policy. If I do not cancel my Procedure upon at least 48 hours’ notice via email, text, or telephone, I will be assessed the full price of Procedure (a “Cancellation Fee”); provided, however, that no Cancellation Fee shall be assessed, regardless of whether I cancel my Procedure within 48 hours of my appointment time, if such cancellation is made because (i) I am exhibiting COVID-19 Symptoms, or I have tested positive for COVID-19 within 48 hours of my appointment; or (ii) I have been in close contact with someone who is exhibiting COVID-19 Symptoms or who has tested positive for COVID-19 within 48 hours of my appointment. Further, I agree that if I do not arrive within 15 minutes of my scheduled appointment time, The Lash Den may cancel or modify my Procedure, and I will be assessed the full price of the Procedure as originally scheduled.
SignatureI agree to the terms and conditions
(Sign Here)
Clear Signature
If Client is a minor under the age of 18:
SignatureI agree to the terms and conditions
(Parent or Guardian's Signature)
Clear Signature