Full Name *

First Name

Last Name

Date of Birth *

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Phone *

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you have any allergies or allergic reaction? *

Yes

No

Have you had eyelash extensions before? *

Yes

No

Do you perm or tint your lashes? *

Yes

No

Have you been using an eyelash serum/conditioner? *

Yes

No

If any of the following applied to you in the past 6 months, please check: *

Allergies to adhesives in Band Aids or medical tape?

Eye illness or Injury?

Allergy to surgical glue or nail glue?

Seasonal allergies?

Blepharitis (inflamed eyelids)?

NONE

Do you have? (Check all that apply): *

Hormone imbalance or extreme stress?

Recent severe illness or major injury?

Pregnancy or recent childbirth?

Conditions that contribute to hair and eyelash loss?

Chemotherapy, blood thinners (anticoagulants) or blood pressure med *beta blockers)?

Medication prescribed for hair loss, thyroid disease, alopecia, lupus or diabetes?

NONE

All boxes must be checked. By doing so, you have read, understood and agree to the terms. *

I authorize Dreamluxe LLC dba Dreamluxe Esthetics and all affiliated lash artists to provide and apply semi-permanent eyelash extensions to my eyelashes.

I understand, agree to follow and know that I can find the eyelash extension aftercare instructions at https://www.dreamluxeesthetics.com/aftercare-lashes

I understand that each eye sheds 2-5 lashes per day and I will need to maintain my extensions with touch up appointments usually recommended every 2 to 3 weeks to keep them looking optimal. I understand that variables including my lifestyle, hormones and time of year will influence the longevity of my eyelash extensions.

I understand and agree that there is no patch test given and if I experience an allergic reaction that I will contact Dreamluxe Esthetics to have the eyelashes removed immediately and consult a physician at my own expense. Dreamluxe Esthetics has a 48 hour removal policy. After that, there will be a $25 removal fee.

I understand and have read "Jackie's Policies" prior to booking my appointment and agree with all policies stated including non-refundable, non-transferable, cancellation, late and rescheduling policies.

I grant permission for Dreamluxe, LLC and my lash artist to use my before and after photos and videos for marketing purposes or to display. DO NOT check box if you opt-out of this permission.

By signing this client waiver and release agreement, I, the client named below certify that I knowingly and voluntarily release Dreamluxe, LLC and it's directors, officers, owners, employees, agents and representatives from any and all claims for damages for personal injury arising from the application and use of semi-permanent eyelash extensions including, but not limited to claims for negligence and pre-existing conditions.

This agreement will remain in effect for this procedure and all future procedures conducted by Dreamluxe, LLC dba Dreamluxe Esthetics and all affiliated lash artists for the entire duration of my time using the services at Dreamluxe Esthetics.

I represent that I am or over the age of 18 years. If under 18, parent must sign this form and will therefore grant consent.

I certify that I have read and fully understand this Client Consent Form. I further certify that I have completed the Client Waiver & Release Agreement accurately and completely to the best of my knowledge, and that I understand the potential complications and risks described. I hereby authorize Dreamluxe, LLC dba Dreamluxe Esthetics and all affiliated lash artists to provide and apply semi-permanent eyelash extensions to my natural eyelashes, in accordance with the terms and conditions set.

I have not traveled within the last 2 weeks and am not experiencing any COVID-19 symptoms.

Today's Date *

MM

DD

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