omer Remarks ID: 113858
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ime: D: _____/ ______/ _______ T: __________Your CertiÞed Lavish Lashes Specialist is:____________________________________Locataion of Service: ____________________________________Preferred Appointment Day: omer Remarks: _______________________________________________________________________________________________________________________________________________________________________________________________________How did you hear about us? ! Lavish Lashes Web Site ! Magazine ! Google/web search ! Friend ! Other: _____________________________________Is this the !rst time you have had lash extensions applied? ! Yes ! No ! a special occasion -or- ! daily wear Are you: ! From the area ! Just visitingDo you wear contacts? ! Yes ! No Do you habitually rub, pull, or pick your lashes for any reason? ! Yes ! NoDo you have, or are you being treated for any eye illness or injury? ! Yes ! NoWhat side do you predominately sleep on? ! Right ! LeftPlease 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? ! Yes ! NoPlease check o" any of the following that might apply to you:! Lasik Eye Surgery ! Permanent eye make-up yanoacrylate or formaldehyde or certain adhesiv Accutane or Retin A) CONSENT FOR EYELASH PROCEDURE:I have ag isks associated with the procedure and product itself, which include, without limitation, eye irr . I also agree to defend, indemnify and hold harmless Professional and Lavish Lashes, LL 2. Permission to Use Pictures. I hereby grant to Professional and Lavish Lashes, LLC the full right to take, publish and reproduce phot eness as contained in these ! a Þctitious name: ________________________________________3. Care and Maintenance. I ag care of my Lavish Lashesª, and that if any follow up care is required due to my own mistake or negligence, or failure t ye products as these will loosen the bond of my Lavish Lashesª. I will avoid getting my lashes wet within the Þrst 24 hours after my application. For the Þrst tw tensions removed. I agree to avoid using waterproof mascara and to not use an eyelash curler, perm, or tint my La o this agreement, and his or her relationship to me is as follows: _______________________________. By his or her signature below, he or she ratiÞes and consents to this procedure under these terms.Signature: ________________________________________ Print Name: ______________________ Date: _________________Parent/Guardian Signature: __________________________ Print Name: ______________________ Date: _________________©2007 Lavish Lashes, LLC All Righ