• Name: *

  • Date: *

  • Address: * City: * State: * ZIP: *

  • Birthday: * Phone: *

  • Email: *

  • Occupation: *

  • How did you hear about us? Please circle one:

  • Is this the first time you had lash extension applied?

  • if no, where have you had them applied?

  • Please indicate if you have worn within the last 60 days any of the following types of lashes:

  • Individual Strip Flare Other

  • Are you having lash extension applied for: A special occasion Daily wear

  • Are you: From the area Just visiting

  • Do you wear contacts?:

  • Do you habitually rub, pull, or pick your lashes for any reason?

  • Do you have, or are you being treated for any eye illness or injury?

  • What side do you predominately sleep on?

  • Please list any eye drops or eye medication you are using?

  • Are you able to keep your eyes closed and lie still for up to 2 hours or longer?

  • I have agreed to have DuPont’s eyelash extensions applied to and/or removed from my eyelashes.

    Before my qualified professional can perform this procedure, I understand I must complete this agreement and provide my informed consent by signing and dating where indicated below. For valuable consideration, to have my DuPont Lash extensions applied and/or removed from my eyelashes:

    1. Waiver of Liability. I understand there are risks associated with having artificial eyelashes applied to and/or removed from my existing eyelashes, and that notwithstanding the utmost care in the application or removal of these products, there still exist risks associated with the procedure and product itself, which include, without limitation, eye irritation, eye pain, discomfort, and in rare cases, blindness when improperly handled.

    As part of this procedure, I understand that a certain amount of eyelash adhesive material will be used to attach the artificial lashes to my existing eyelashes. Even though the Professional may apply or remove my lashes properly, I understand adhesive material may become dislodged during or after the procedure, which may irritate my eyes or require further follow- up care, at my own expense to prevent damage to my eyes. I also understand there is more than one technique for applying the lashes to my eyelashes, and I will not attribute any liability to DuPont Brow and Lash Studio as a result of this procedure or the use and care of these lashes. I also agree to defend, indemnify and hold harmless DuPont Brow and Lash Studio from all claims, actions, expenses, damages, and liabilities, including reasonable attorney fees which might be asserted against them as an agreement, the terms DuPont Brow and Lash Studio include all of their respective officers, directors, agents, employees, successors, and assigns.

    2. Permission to use Pictures. I hereby grant DuPont Brow and Lash Studio the full right to
    take, publish, and reproduce photographs of me, my face, my eyes, and/or eyelashes, both before and after this procedure, for any advertising, education, or other purposes whatsoever, including the to retouch these photographs as deemed necessary by DuPont Brow and Lash Studio. I further expressly assign any copyright in these photographs to DuPont Brow and Lash Studio. I also grant my consent for DuPont Brow and Lash Studio to use my image and likeness as contained in these photographs for any advertising or other purposes, along with any comments I may provide. Please use these images with the following:

  • my own name no name to be used a fictitious name

  • 3. Care and Maintenance. I agree to follow the care and maintenance instructions provided by DuPont Brow and Lash Studio and/or Professional for the use and care of my DuPont lashes, and that if any follow-up care is required due to my own mistake or negligence, or failure to follow these instructions will be at my own expense and risk. I understand that if I do any of the following, it may result in damage to my lashes or may cause my lashes to fall off prematurely.

    Knowing this I agree to follow these tips for best results: I will avoid oil-based eye products, as these will loosen the bond of my lashes. I will avoid getting my lashes wet within the first 24 hours after my application.

    For the first two days after application, I understand it is best to avoid swimming, saunas, or steam rooms. If I experience any itching or irritation, I agree to contact my DuPont Brow and Lash Studio professional immediately to have the lash extensions removed. I agree to avoid using waterproof mascara and to not use an eyelash curler, perm, or tint my DuPont lashes. I agree not to pick, pull, or rub my lashes. I understand that I should not attempt to remove my lash extensions on my own or with any product, but that the procedure requires that my lash extensions be professionally removed.

    4. No Known Medical Conditions/ Informed Consent. I have read and completed the DuPont Brow and Lash Studio client Intake Form in its entirety and truth. I acknowledge that I have been advised of the potential harmful or negative side effects (such as the premature shedding of my eyelash) that the lash extension procedure or removal may cause to those who have specific medical or skin conditions.

    I understand that the adhesives and adhesive removers are skin, eye, and mucus membrane irritants and that in rare cases people can be allergic or have hypersensitivity to synthetics, cyanoacrylate, or formaldehyde, which in small amounts can be present in the adhesive. I understand that the procedure requires that I lay still for up to 2 hours or longer with my eyes shut and if I wear contacts, I must remove contact lenses for the duration of the lash extension application or removal. I further state that I have no known medical condition that might be aggravated by the procedure or any medical condition that would prevent me from complying with or heeding to the Professionals or DuPont Lash instructions or these warnings.

    If any action is brought to enforce the terms of this Agreement, the prevailing party shall be entitled to its costs and reasonable attorney’s fees. Any claims arising out of this agreement will be resolved through binding arbitration using the rules of the American Arbitration Association. This agreement will remain in effect for this procedure, and all future procedures conducted by the professional or any other professional conducting business at (salon/ establishment name and address). I agree that this Agreement is binding upon me, and my heirs, legal representatives, and assigns. I represent that I am over 18 years of age and that I have the right to enter this agreement, or if I am under 18 years of age, I have had my parent or legal guardian consent to this agreement, and his or her relationship to me is as follows by his or her signature below, he or she ratifies and consents to this procedure under these terms.

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