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If you check all of the items below, then you are an ideal candidate for eyelash extensions. If you do not check one of the items below, consult with our stylists for further information to ensure beautiful, long-lasting results and a comfortable and relaxing experience.
Required*
Are Eyelash Extensions right for you? Check off all that apply*
To ensure long -lasting eyelash extensions and a comfortable and relaxing experience, prepare for your application*
I authorize a Chic Lash Boutique, Xtreme Lashes trained stylist, hereinafter collectively referred to as my "stylist" to perform the semi-permanent eyelash extension procedure. I understand this procedure requires individual synthetic eyelashes to be glued to my own natural lashes. I understand it is my responsibility to remain still during the application and to keep my eyes closed during the entire process until otherwise advised. I acknowledge that my stylist has explained to me the methods and procedures concerning the application of semi-permanent eyelash extension application and that there are certain complications and risks inherent both in the application process and in wearing semi-permanent lashes. These risks may include, but are limited to, temporary eyelash loss as a result of improper application techniques or through improper post-application care, transient eye redness and irritation, and allergic reaction to the adhesive, under-eye gel patches and other products.
I hereby consent to the procedure at my own risk. If at anytime I am uncomfortable with the eyelash extension procedure, I will inform my stylist and s/he will use good faith efforts to rectify the problem, including ending the session if I (or my stylist) wish.If my stylist is uncomfortable applying lashes to me, s/he will discuss his/her concerns with me and may end the session if necessary. I acknowledge that I have received no guarantees, warranties, promises, and/or commitments regarding the application process or the products used or applied therein or other statements as to the results of this service. I have revealed or disclosed on the Client Registration, Eyelash History, and the Client Consultation & Design Form all conditions and circumstances regarding my health and health history, medications being taken and any past reactions to products used or medications taken. Additional conditions could occur or be discovered during or after the procedure, which could affect my ability to tolerate the procedure.
I understand that the duration of my eyelash extensions requires my careful maintenance. I understand that it takes 48 hours for the adhesive to cure (dry) thoroughly and that the following activities should be avoided, as they will interfere with this curing process, resulting in a weaker bond, premature lash extension loss, and/or irritation: showering, exposure to heat, steam, sauna, and friction; application of eye and eyelash cosmetics; sleeping on the side or stomach; receiving chemical treatments; and receiving irritating eye-area treatments. I also understand that even after the first 48 hours after application, I need to avoid excessive swimming, sauna, steam rooms, pulling on lashes, using oil-based or waterproof cosmetics, and using mechanical curlers or crimping lashes in any way. I understand that failure to follow these instructions may cause irritation, reaction, eyelash loss, and other side effects described in this form. I understand that the eyelash extension application risks and the post-application care and maintenance described herein apply equally to initial eyelash and subsequent touch-up applications.
I, THE UNDERSIGNED, HEREBY FULLY RELEASE, WAIVE, COVENANT NOT TO SUE, AGREE TO HOLD HARMLESS, AND FOREVER DISCHARGE my stylist, Xtreme Lashes LLC, their affiliates, agents employees, officers, directors, independent contractors, and any and all partnerships, corporations, or companies associated with them, from any and all liabilities, demands, claims, losses, injuries, or damages, including court costs and attorneys' fees and expenses, of any nature arising out of or relating to the application of semi-permanent eyelash extension products, EVEN THOUGH CAUSED IN WHOLE OR IN PART BY A PRE-EXISTING DEFECT, THE NEGLIGENCE (WHETHER SOLE, JOINT, OR CONCURRENT), GROSS NEGLIGENCE, STRICT LIABILITY OR OTHER LEGAL FAULT OF MY STYLIST OF OR XTREME LASHES LLC. IT IS MY EXPRESS INTENT THAT THE ABOVE RELEASE INCLUDES THE RELEASE OF MY STYLIST AND XTREME LASHES LLC (INCLUDING THE INDIVIDUALS AND ENTITIES LISTED ABOVE) FROM THE CONSEQUENCES OF THEIR OWN NEGLIGENCE. It is also my express intent that this Waiver and Release Form shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representatives, if I am deceased, and shall be governed by the laws of the State of Texas. I further agree that, should I choose to seek the advice of an attorney regarding said release, I will be responsible for any and all costs of legal services that I incur. I agree that this release shall be in contemplation of any possible damages, either known or unknown at the signing of this waiver and release form, and said damages are specifically waived following the signing of this waiver and release form. I further agree that in the event that any dispute that arises out of or relating to the application of semi-permanent eyelash extension products and/or terms of this Waiver & Release between me, or anyone acting on my behalf, my stylist and/or anyone affiliated with my stylist shall be resolved by binding arbitration before the American Arbitration Association. The exclusive venue for arbitration against my stylist shall be the city and state in which the stylist resides at the time the arbitration is initiated; provided, however, that the should arbitration be initiated against Xtreme Lashes, LLC, in addition to or exclusive of my stylist, the exclusive venue for such arbitration shall be in Houston, Harris County, Texas. I agree that I will be responsible for and will pay all court costs, arbitration costs, attorneys' fees and expenses, and other associated costs incurred by my stylist or Xtreme Lashes, LLC in seeking enforcement of this Waiver & Release. I further release my stylist from any responsibility for pre-existing conditions I have not revealed, or any consequential change to those conditions that arises subsequent to the procedure. I understand that I am responsible for any medical treatment I may need to receive as a result of getting this procedure. I accept full responsibility for these and any other complications, which may arise or result during or following the eyelash extension procedure(s), which are to be performed at my request.
I, the undersigned client, certify that I have read and had explained to me and fully understand the above waiver and release form and am electronically signing it voluntarily as my own free act and deed. I certify that I have consulted with a stylist and have read all applicable literature given to me. I have completed the Client Registration, Eyelash History, and the Client Consultation & Design Form to the best of my knowledge. I accept the explanation of potential complications and risks described herein. I certify I am of sound mind and I am fully capable of executing this waiver and release form for myself. No oral representations, statements, or inducements apart from the foregoing agreement that has been reduced to writing have been made.
I, the undersigned client, acknowledge and fully understand that there might be other known risks not reasonable foreseeable at this time. I, undersigned client, acknowledge that I have read and agree to the provisions, terms, and conditions provided in the Xtreme Lashes, LLC Waiver and Release Form. I agree to assume all risks of injury associate with eyelash extension application, and agree to hold harmless the stylist and/or anyone affiliated with said professional including, but not limited to, Xtreme Lashes, LLC.
I, the undersigned client, hereby give Chic Lash Boutique LLC and its affiliates, the absolute right and unrestricted permission to take, use, and display photogenic images of me, through any form of media (print, digital, electronic, broadcast, or otherwise) at any location for art, advertising, media release news articles, marketing, publicity, archival, or any other lawful purpose. I waive any right to royalties or other compensation arising from or related to the use of photogenic images of me. I release and agree to hold harmless Chic Lash Boutique LLC and its affiliates from any liability in connection to taking or using said images.
I authorize a Chic Lash Boutique lash professional to perform the silicone eyelash perm procedure. I understand this procedure requires my lashes to be glued to a silicone pad and curled with a chemical curling agent, a conditioning agent, and a nourishing oil. I understand that it is my responsibility to be still during the procedure and to keep my eyes closed during the process unless otherwise advised. I have been fully informed as to the methods and procedures concerning the silicon eyelash perm procedure. The risks of the cosmetic procedure I have chosen have been disclosed to me. Some cases may result in complications such as transient eye redness, irritation and allergic reaction to the products used to perm the lashes and or the tape or anti wrinkle gel patches. If at any time I (or the technician) are uncomfortable with the eyelash perming procedure, I will inform the technician and she will gladly rectify the problem, including ending the session as I (or the technician) wish. It has been represented to me that no guarantees, warranties, promises, commitments or other statements as to the results of this treatment have been made. I acknowledge that I have no particular representation or guarantees, and I am consenting to the procedure at my own risk. All conditions must be revealed or disclosed by me to the technician regarding health history, medications being taken and any past reactions to products used or medications taken. Additional conditions could be discovered during the procedure, which could affect my ability to tolerate the procedure.
I herein signed, release, give up, acquit and discharge Chic Lash Boutique and my lash professional and or anyone affiliated there to including any partnership, corporations or company associated with said individual from any claims or damages of any nature. I agree to pay any costs of legal services necessary to affect said release. I further agree that this release shall be in contemplation of any possible damages, either known or unknown at the signing of this release and said damages are specifically waived following the signing of the release. I further agree that in the event any litigation ensures, it shall be placed before the American Arbitration Association or some other such arbitrator for resolution. I agree that in the event a decision is determined in favor of one party over the other, the prevailing party shall be entitled to reasonable attorney fees and costs as set by the arbitrator. I further agree to hold my Chic Lash Boutique lash professional nameless and harmless from any and all damages. I release my Chic Lash Boutique lash professional from any responsibility for pre-existing conditions I have not revealed or any consequential change to those conditions that arise subsequent to the procedure. I accept full responsibility for these and any other complications, which may arise or result during or following the silicone eyelash perm procedure(s), which are to be performed at my request.
Please read the following statement and sign and date on the line to indicate that you have read the statement and understand it; I, the client herein signed, 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 a Chic Lash Boutique lash professional and have read all applicable literature given to me. I have provided information regarding my health and medications taken to the best of my knowledge. I accept the explanation of potential complications and risks described herein. I certify I am of sound mind, and fully understand that there might be other unknown risks not reasonably foreseeable at this time.
I, the client herein signed, for the purposes of documentation, hereby consent to any “before and after” photographs, which may or may not be used for the purposes of advertising.
The undersigned acknowledges that the technician has explained the nature of the above-noted treatment procedure herein. I hereby consent to the technician performing the above-noted treatment procedures on me and in consideration of their doing so, I hereby and forever discharge Chic Lash Boutique, its officers and employees of and from all claims, demands, damages, actions and cause of action arising out of the performance of the said treatment procedures, which I, my heirs, executors, administrators, or assigns can, shall or may have. Being of sound mind and body, I hereby release any and all persons representing the Chic Lash Boutique from all responsibility. I accept all responsibility myself for any consequences that might stem from my decision to have eyelash / eyebrow tinting work done.
You are hereby notified of the possible risks and dangers associated with the application of each tattoo. These risk and dangers include, but are not limited to, at least the following:
NO PERSON MAY BE TATTOOED WHO APPEARS TO BE UNDER THE INFLUENCE OF ALCOHOL OR DRUGS.
An artist may not tattoo a person younger than 18 years of age without meeting the requirements of 25 Texas Administrative Code, §229.406(d), whose parent or guardian determines it to be in the best interest of the minor child to cover an existing tattoo.
Are you currently under the care of a physician?
Yes No
If so, what condition?
Physician Name
Phone
Asthma
Seizures
Epilepsy
Lupus
Neck/Back Pain
Arthritis
Pacemaker
Mental Illness
Hemophilia/Bleed Easily
Diabetes: Type 1
Diabetes: Type 2
Autoimmune Disease
Anemia
Cancer
Headaches
High Blood Pressure
Low Blood Pressure
Mitral Valve Prolapse
Thyroid Condition
Alopecia
Stroke
AIDS/HIV
Chemotherapy/Radiation
Heart Disease/ Condition
Herpes/Cold Sores
Fainting
Hepatitis
Bruises Easily
Not Applicable
Other Specific Details:
Skin Type: Normal Dryskin-type Oily Combination Combination
Pore Size: SMALL AVERAGE LARGE
Keloid Scars
Surgical Scars
Psoriasis
Dermabrasion
Hyperpigmentation
Glycolic Acids or Peel Use
Acne
Skin Sensitivities
BOTOX
Dermal Fdermal-fillersillers
Hypopigmentation
Prior Permanent Make-Up
Laser Treatments
Skin Allergies
Vitiligo
Retina Use
Do you wear water-proof mascara or eyeliner? Yes No
Eye Infections
Contact Lenses
Corneal Abrasion
Dry Eyes
Visual Disturbances
Conjunctivitis (Pink Eye)
Eye Allergies
Light Sensitivities
Latisse or Lash Growth Serum
Glaucoma
Fever Blisters
Dentures
Topical Anesthetics
Late
Penicillin
Silver
Lidocaine
Hair Coloring
Foods
Nickel
Iodine
Hay Fever
Nuts/Peanuts
Bee Stings
Make-Up
Anti-Depression
Mood Enhancers
Accutane
Chemotherapy
Cold Sore Meds
Anti-Anxiety
Hormone Replacement
Caffeine
Alcohol
Vitamin E/Fish Oil
Blood Thinners
Aspirin
Blood Pressure Meds
Thyroid
Radiation
Type of ID:
ID #:
Verified By:
Name:
Phone:
Relationship:
1. How did you hear about us?
2. How do you heal from a cut?
Fast Normal Slow
2a. Heal type?
Keloids Heals with thick scaring Heals white-hypopigmentation
3. Are you or could you be pregnant or nursing? Yes No
4. Do you currently tan? Yes No
When was your last exposure to the sun or tanning bed?
5. Do you or are you spray tanned? Yes No
6. Ethnicity:
NOTE: All information must be accurate and complete. All information provided is valuable to your technician as each person’s body is unique or it may indicate health conditions or medications that may affect healing. If this form has not addressed a medical/health condition or medication please list it on the back. It would be advisable that you consult with your physician prior to proceeding with any procedure. Continue taking an medications in accordance to your doctor’s directions. If you are unsure if your prescribed medication you are using is a blood thinner, contact your physician. Physician Medical Release request, It will be required and must be signed, dated and emailed directly to the technician. This form is required prior to scheduling any procedure. Should your medical health condition change, advise us of any changes when scheduling.
By signing below, I am acknowledging the above information to be accurate and I will advise the technician of any changes to my medical health condition.
Micro Stroke Brows
I am at least 18 years of age. I am not under the influence of drugs or alcohol. I accept any and all responsibility for consequences that might stem from my decision to have the cosmetic or permanent make-up tattoo process. I have, of my own free will, elected to have this cosmetic or permanent make-up tattoo procedure and consent to the application of the procedure and to its attended risks, and to any actions or conduct of the practitioner reasonably necessary to perform the procedure(s).
The nature and method of purposed cosmetic tattoo procedure(s) has been explained by the technician, the risks inherent in the procedure process, and the possibility of complications and have been given the opportunity to ask questions. I understand there may be a certain amount of discomfort or pain associated with the procedure(s) and that other adverse side effects may include minor and temporary bleeding, bruising, swelling, and/or redness or other discolorations. Fading or loss of pigment may occur. Unevenness in design may occur due to swelling. Secondary infection in the area of procedure may occur, however, if all aftercare instructions (that were provided) are followed, is rare. By executing this form, you agree that a technician’s representative has reviewed cosmetic tattoo procedures and processes with you, and addressed all your questions and concerns.
To my knowledge, I do not have any physical, mental or medical impairment or disability which might affect my wellbeing as a direct or indirect result of my decision to having cosmetic or permanent make-up tattoo procedures. I do not have any health issues that would prevent me from having the cosmetic tattoo process applied by the technician or its employees. I will advise my technician if I have any condition that may affect the healing from this kind of procedure such as diabetes, epilepsy, hepatitis, hemophilia, HIV-AIDS, or any other communicable disease, heart condition or take medication which things the blood. I will inform the technician of any health problems or changes.
This cosmetic, elective, non-medical procedure is being performed using standard aseptic technique and sterilization methods recommended by the Center for Disease Control. This inludes the dispensing of all consumables for single use on one client in front of the client The device used for implanting pigment can be disassembled and the non-motor parts discarded.
I have fully informed in regards to the procedure of cosmetic or permanent make-up tattoo related procedures. It has been explained to me the typical results of my elective procedure may be, however, complications may occur that include corneal abrasion, fever blisters, redness, swelling, bruising, tingling and discomfort, infection, scaring, and allergic reactions. I have been advised specifically with regard to possible allergic reaction to a local anesthetic or preservatives, solutions, pigments and latex. I understand allergic reactions may occur, sometimes severe, with permanent cosmetic pigments at any point in time. Understand the risk, I wish to have permanent cosmetic tattoo procedure(s).
The technician has explained to me what the typical result of procedures following a previous technicians work, whether correction, with or without removal, color refresher/booster. No promises or guarantees of any kind have been made to the final outcome. Pigment may not retain in the area of tattoo removal due to damaged tissue and scaring. Pigment may not retain over previous procedures or work, due to the saturation level of pigment and/or scar tissue caused from the previous work. Complications may occur that include hypopigmentation, hyperpigmentation, corneal abrasion, fever blisters, redness, swelling, bruising, tingling and discomfort, infection, scaring, and an increased risk of allergic reaction occurring. I have been advised that using another supplier’s pigment over my existing can encourage this reaction.
I acknowledge that complications are always possible as a result of the cosmetic tattoo procedure, particularly if aftercare instructions are not followed. I have received a written copy of pretreatment and aftercare instructions and will follow them while the procedure area is healing. I will contact the technician with any all questions and concerns that may arise.
I full understand that the permanent cosmetic tattoo procedure(s) are a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove it in the future.
I fully understand there is no pigment or ink FDA approved for the purpose of any type tattooing.
Tattoo removal, previous permanent make-up, Alopecia, Trichotillomania, skin conditions, or scars in the procedure area, due to tissue and skin healing, you may require multiple procedures and/or there’s a chance the pigment may not retain at all.
I give permission without restriction to allow all photography of the treated area and may include full face photos of before, during and after the procedure, and final healed result for use in the technician, it’s employees’ or contractors’ portfolios, website and advertising.
I have been advised this procedure will be video and sound recorded for verification of sanitation and disinfection to meet the standards recommended by the Center for Disease Control.
I understand that should it be decided that any client cannot continue a procedure, due to too much movement, safety issues, personal tolerance or any other reason, once the procedure has been started, it will then be considered completed and applicable fee will be due in full. Said procedure will not be rescheduled or refunded. There will be additional fees for any ongoing procedures.
I understand that the technician may request a Physicians Medical Release; it must state you qualify for cosmetic tattoo procedures, be signed, dated and emailed to the technician directly from the physician’s office. This release is required prior to scheduling or receiving a procedure.
I understand that I may not be able to donate and/or sell blood for 1 year after any procedure.
Titanium Dioxide is an ingredient used in micropigmentation colors. Lasers can permanently alter the color of titanium dioxide of micropigmentation tattoos and may not be able to be removed and/or corrected.
I understand that a MRI may be affected by the application of tattooed permanent make-up. It is understood that I will advise my physician that I have cosmetic tattooing in the event an MRI is prescribed. For more information, visit www.MRIsafety.com._(inti.)
This contract will remain in full effect for as long as I am a client of the technician and all of its contents will apply whenever work is being performed on myself by the technician. It is my responsibility to inform the technician if changes have occurred in my medical/health history.
I have been fully advised of the risks associated with this procedure and cosmetic tattooing is an art form and NOT an exact science. I acknowledge that NO guarantees have been made as to the final result of this procedure and the necessary steps that it will take to remove and/or correct the cosmetic or permanent make-up tattoo I am receiving.
I accept full responsibility for determining color, shape and position of the pigments that will be applied. I understand that the actual healed color of the pigment applied will be modified slightly due to my own unique skin undertones.
Some skin types will not accept or heal pigment in a consistent manner…your skin and how well you take care of the procedure area will determine your result. I realize that my body and my skin is unique and that the technician cannot in any way predict how many visits it will take to complete my procedure.
It has been explained to me that immediately after the procedure(s) is completed, the color will appear darker and/or brighte r and the design will appear to be thicker. It has also been explained to me that within a short period of time (usually 5-7 days) during the healing process, the color will soften/lighten and the design will heal thinner than it looked the day it was performed.
I acknowledge that hyper-pigmentation (darkening of the skin) or hypo-pigmentation (absence of color in the skin), scarring is a possibility as a result of my body’s reaction to the skin being broken during the procedure. I realize the body is unique and that the technician cannot predict how my body will react as a result of this procedure.
I understand that future laser treatments, plastic surgery, implants or fillers and any other skin altering procedures may alter or degrade my cosmetic tattoo procedure(s). I further understand that such changes are NOT the responsibility of the technician, and such changes in my appearance my NOT be correctable though further cosmetic tattoo procedures._ (init.)
I fully understand that cosmetic and permanent make-up tattoo is permanent and can take repeat procedures to achieve the desired effect. The fee(s) for your cosmetic tattoo procedure(s) have been explained to me, including initial procedure fee, follow up fees and maintenance color refreshers/booster fees. Please refer to Our Policies. These fees are understood and agreed upon, I understand the total fee for services rendered is due upon completion of the initial procedure and there WILL BE separate fees for any follow up or ongoing procedures.
I accept full responsibility for determining the color, shape and position of the pigments that will be applied. I understand actual color of pigment may be modified slightly due to my own unqie skin tone, undertones and color of my skin.
Redheads, blondes, and fair skin will be red, swollen and pigment MAY not take. Additional procedures may be required to obtain desired results.
I acknowledge that hair stroke brow procedure pigment implanted in darker skin tones will appear softer and blend more with your own skins melanin and not appear as bold or crisp as on lighter skin tones.
Hair stroke eyebrow WILL with time and aging, become more solid and powdered looking. Frequent tanning and sun exposure WILL fade pigment quicker.
Smoknig will affect your results and may cause the pigment to fade prematurely.
I understand that if I have severely oily skin the pigment will appear much softer and hair strokes can look more solid due to the over-production of the oil glands. The pigment WILL fade quicker and may require more frequent color refresher/boosters.
I fully understand that with age and time that pigment may no longer retain in your skin. Color refreshers are recommended every 1-3 years or as needed to keep color fresh._ (init.)
I acknowledge that I have received a copy of detailed after care instructions in writing and will follow them. I agree to fol low the instructions concerning the care of my cosmetic tattoo while it is healing. I understand that after care is crucial for optimum results and if I do not follow the strict after care instructions, I can ruin my results. I will contact the technician with any all questions and concerns that may arise.
The technician can release me as client should I not be compliant with procedure polocies or elect to have another artist/technician apply cosmetic tattooing over an area originally done by the technician; I understand that I will no longer be a candidate for ongoing procedures or corrections provided by the technician.
Additional Details and / or Information
I acknowledge by signing this consent form that I have been given the full opportunity to ask any and all questions about cosmetic tattooing procedure, its process, and the risks involved by the technician. The decision to have cosmetic tattoo procedure(s) performed by The Technician is my own and I understand and accept all risks involved, therefore hereby releasing the technician, its employees, heirs and assigns from all manner of legal liabilities, claims, actions, and demands, in law or in equity, which I or my heirs have or might have now or hereafter by reason of complying with my request for said procedure. Cosmetic tattooing is not a medical procedure by an art form, the art of tattooing. I ACKNOWLEDGE THAT NO GUARANTEES OR PROMISSES HAVE BEEN MADE TO ME CONCERNING THE RESULTS OF THIS PROCEDURE AND THAT THE PROFESSIONAL RECOMMENDATION IS A NATURAL LOOK. Due to the fact your approval is obtained prior to final selection of color to be implanted and design application(s),that all the facts about cosmetic tattooing have been disclosed and discusses with you.
I, undersigned, have read each paragraph, understand, acknowledge and agree to all of the above terms and conditions.
I, authorize a Chic Lash Boutique professional to perform the Brow Lamination/Eyebrow Perm procedure. I understand this procedure requires my eyebrows to be treated with a chemical perming agent, a setting agent, and a nourishing oil. I understand that it is my responsibility to be still during the procedure and to keep my eyes closed during the process unless otherwise advised. I have been fully informed as to the methods and procedures concerning Brow Lamination procedure. The risks of the cosmetic procedure I have chosen have been disclosed to me. Some cases may result in complications such as redness, irritation and allergic reaction to the products used to perm the brows. If at any time I (or the technician) are uncomfortable with the Brow Lamination procedure, I will inform the technician and she will gladly rectify the problem, including ending the session as I (or the technician) wish. It has been represented to me that no guarantees, warranties, promises, commitments or other statements as to the results of this treatment have been made. I acknowledge that I have no particular representation or guarantees, and I am consenting to the procedure at my own risk. All conditions must be revealed or disclosed by me to the technician regarding health history, medications being taken and any past reactions to products used or medications taken. Additional conditions could be discovered during the procedure, which could affect my ability to tolerate the procedure.
I herein signed, release, give up, acquit and discharge Chic Lash Boutique and my professional and or anyone affiliated there to including any partnership, corporations or company associated with said individual from any claims or damages of any nature. I agree to pay any costs of legal services necessary to affect said release. I further agree that this release shall be in contemplation of any possible damages, either known or unknown at the signing of this release and said damages are specifically waived following the signing of the release. I further agree that in the event any litigation ensures, it shall be placed before the American Arbitration Association or some other such arbitrator for resolution. I agree that in the event a decision is determined in favor of one party over the other, the prevailing party shall be entitled to reasonable attorney fees and costs as set by the arbitrator. I further agree to hold my Chic Lash Boutique professional nameless and harmless from any and all damages. I release my Chic Lash Boutique professional from any responsibility for pre-existing conditions I have not revealed or any consequential change to those conditions that arise subsequent to the procedure. I accept full responsibility for these and any other complications, which may arise or result during or following the Brow Lamination procedure(s), which are to be performed at my request.
Please read the following statement and sign and date on the line to indicate that you have read the statement and understand it; I, the client herein signed, 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 a Chic Lash Boutique professional and have read all applicable literature given to me. I have provided information regarding my health and medications taken to the best of my knowledge. I accept the explanation of potential complications and risks described herein. I certify I am of sound mind, and fully understand that there might be other unknown risks not reasonably foreseeable at this time.
Micro-Current Users:
The NuFace Trinity Device should not be used by minors, pregnant women, people subject to seizures, people with cancer/tumors, people with cardiac pacemakers, people with implanted defibrillators/stimulators, people with electronic implanted devices.
RELEASE AND WAIVER
The undersigned acknowledges that the technician has explained the nature of the above-noted treatment procedure herein. I hereby consent to the technician performing the above-noted treatment procedures on me and in consideration of their doing so, I hereby and forever discharge Chic Lash Boutique, its officers and employees of and from all claims, demands, damages, actions and cause of action arising out of the performance of the said treatment procedures, which I, my heirs, executors, administrators, or assigns can, shall or may have. Being of sound mind and body, I hereby release any and all persons representing the Chic Lash Boutique from all responsibility. I accept all responsibility myself for any consequences that might stem from my decision to haveNuFaace Microcurrent Therapy work done.
I understand and have read this waiver. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contradictions and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and /or skin care professional from liability and assume full responsibility thereof.
The undersigned acknowledges that the technician has explained the nature of the above-noted treatment procedure herein. I hereby consent to the technician performing the above-noted treatment procedures on me and in consideration of their doing so, I hereby and forever discharge Chic Lash Boutique, its officers and employees of and from all claims, demands, damages, actions and cause of action arising out of the performance of the said treatment procedures, which I, my heirs, executors, administrators, or assigns can, shall or may have. Being of sound mind and body, I hereby release any and all persons representing the Chic Lash Boutique from all responsibility. I accept all responsibility myself for any consequences that might stem from my decision to have facial work done.
1. Within the last year have you been under a dermatologist's or physician's care? Yes No
a. If yes, please specify?
2. Have you had any health problems in the past or present? Yes No
3. List any medications, supplements, vitamins, diuretics, slimming pills, Isotretinoin, etc. that you take regularly.
4. Do you smoke? Yes No
5. Do you exercise regularly? Yes No
6. Do you follow a restricted diet? Yes No
7. Do you wear contact lenses? Yes No
8. Do you have metal implants, a pacemaker or body piercings? Yes No
9. Rate your level of stress on a scale of 1 to 5
10. Do you have any allergies (latex, nickel, etc.)?
11. Have you had an allergic reaction to Aspirin? Yes No
12. Do you sunbathe or use tanning beds? Yes No
13. Do you drink more than 4 caffeinated beverages daily? Yes No
14. Have you ever experienced claustrophobia? Yes No
1. What are your specific concerns or challenges with your skin?
2. What skin care products are you currently using? a. Face: soap cleanser toner moisturizer masque exfoliator eye products serums b. Body: soap shower gel scrubs oil body moisturizer depilatory products self-tanners
3. Have you had a chemical peel, microdermabrasion, laser or light therapy, an injectable, or other cosmetic procedure in the last month? Yes No
4. Have you waxed within the last 72 hours? Yes No
5. Do you use Retin-A, Renova, Adapalene, or any other prescription skin products? Yes No
a. In the last 3 months?
6. Have you taken isotretinoin (Accutane) within the last 6-12 months? Yes No
7. Are you currently using any products that contain the following ingredients? Glycolic acid lactic acid any exfoliating scrubs any hydroxy acid product vitamin a derivative (ie Retinol)
8. Do you ever experience these conditions on your skin? Flakiness tightness obvious dryness
9. What SPF sunscreen do you use on your face?
Body?
10. Do you burn easily in moderate sunlight? Yes No
11. Have you had any direct sun exposure within the last 48 hrs? Yes No
12. Do you have a tendency to redness? Yes No
13. Do you suffer from sinus problems? Yes No
14. Are you prone to cold sores or fever blisters? Yes No
15. Are you currently experiencing a breakout? Yes No
16. Do you ever experience burning, itching or stinging sensations on your skin? Yes No
a. Please specify
1. Are you taking oral contraception? Yes No
2. Are you pregnant or trying to become pregnant? Yes No
3. Are you lactating? Yes No
4. Are you currently having or due for your menstrual period? Yes No
1. Do you have any shaving challenges? Yes No
2. Have you started any new medications since your last visit? Yes No
3. What are your expectations with this treatment?
The undersigned acknowledges that the technician has explained the nature of the above-noted treatment procedure herein. I hereby consent to the technician performing the above-noted treatment procedures on me and in consideration of their doing so, I hereby and forever discharge Chic Lash Boutique, its officers and employees of and from all claims, demands, damages, actions and cause of action arising out of the performance of the said treatment procedures, which I, my heirs, executors, administrators, or assigns can, shall or may have. Being of sound mind and body, I hereby release any and all persons representing the Chic Lash Boutique from all responsibility. I accept all responsibility myself for any consequences that might stem from my decision to have scalp micropigmentation work done.
Diagnosis
Emergency Contact Name
Emergency Contact Phone
1. Do you have any history of the following medical conditions? Cancer Diabetes High Blood Pressure Hepatitis Cold Sores Keloid Scarring Psoriasis Eczema MRSA Blood Clotting abnormalities Arthritis Seizures
2. Do you have any other health problems or medical conditions not listed?
3. Are you allergic to creams, cosmetic chemicals, medications or anesthetic compounds that contain lidocaine? Yes No
4. Are you suffering from a disease, an infection or an irritation in the treatment area? Yes No
5. Are you using blood thinners on a regular basis? Yes No
6. Are you pregnant or breastfeeding? Yes No
7. Are you currently under the influence of drugs or alcohol? Yes No
8. If the answer to any of this is yes, please expand:
Please list all medications taken
What are your Goals and Expectations?
I am over the age of 18 and choose to receive the indicated Scalp Micro-Pigmentation procedure. The general nature of cosmetic pigmentation, as well as the specific procedure to be performed, has been explained to me.
I have been informed of the nature, risks and possible complications and consequences of permanent skin pigmentation. I understand the permanent skin pigmentation procedure carries with it known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to: infection, allergic reaction, scarring, keloid, inconsistent color, and spreading, fanning, or fading of pigments. I understand the actual color of the pigment may be modified slightly, due to the tone and color of my skin. I fully understand this is a pigmentation process and, therefore, not an exact science. I request the permanent skin pigmentation procedure and accept the permanence of the procedure as well as the possible complications and consequences of the said procedure.
I hereby consent to the above Scalp Micro-Pigmentation Procedure. In consideration of doing so, I hereby and forever discharge CHIC LASH BOUTIQUE LLC , it's officer and employees of all claims, demands, damages, actions and cause of action arising out of the performance of the said treatment procedure, which I or my heirs, executors, administrators, or assigns can, shall, or may have.
Being of sound mind and body, I HEREBY RELEAS ANY AND ALL PERSONS REPRESENTING CHIC LASH BOUTIQUE LLC FROM ALL RESPONSIBILITY. I accept all responsibility for any consequences that might stem from my decision to have any tattoo related work performed by CHIC LASH BOUTIQUE LLC. I agree that these waivers also pertain to and are designed to protect all establishments where CHIC LASH BOUTIQUE LLC conducts business. I accept the color, design and payment terms in and related to this agreement.
I acknowledge I have received and understand the Pre=Treatment and Aftercare Guidelines from CHIC LASH BOUTIQUE LLC in relation to said Scalp Micro-pigmentation Procedure. I agree to abide by these guidelines in entirety. I understand that in not doing so will directly affect the results of this procedure, which could include additional sessions necessary to achieve expected results, which are not covered in the cost of the current treatment plan.
I understand that the taking of before and after photographs of the said procedure are a condition of such procedure. I have had the procedure explained to me, and I understand this consent and procedure permit. I accept full responsibility for the decision to have this cosmetic procedure performed.
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Type your full name (By typing in your full name you fully acknowledge this act to be used and taken as an electronic signature.):
DOB: Month JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944
Address:
Age:
ID/DL:
All data inputs are confidential and will be used solely for the purposes of the services intended. Please feel free to contact us with any questions or concerns.
MontrosePhone: 713 874−0114 Hours: Monday-Saturday, 10:00am-6:00pm Address: 544 Waugh Dr., Houston, TX 77019
Highland Village Phone: 281.846.6505 Hours: Monday-Saturday, 10:00am-6:00pm Address: 2400 Mid Lane. Suite 320, Houston, TX 77027
Memorial Phone: 281.888.5764 Hours: Monday-Saturday, 10:00am-6:00pm Address: 7951 Katy Freeway Suite C, Houston, TX 77024
