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Dove Esthetics - Paloma T. Pahle-Levesque

Dove Esthetics - Paloma T. Pahle-Levesque

LASH EXTENSION INTAKE FORM

May we photograph your results and share them on our social media or website?

*Please read through these carefully, signing below indicates and ensures your understanding of safety & the contraindications of the lash extension procedure.* Disclaimer Follows -

Disclaimer - While every precaution will be taken to ensure your safety and well being before, during and after your lash extension application there are safety measures in place to protect the service provider as well as the client. Please read carefully & understand these to your best ability. - I understand that a full set of lash extensions can make the appearance of my own lashes about 30-50% thicker, and make my lashes appear 20-50% longer. - I understand that lash extension services have some inherent risk of irritation to the orbital eye area, including the eye itself, and could result in stinging and burning, blurry vision and potential blindness should the adhesive enter the eye or should an allergic reaction occur. - I understand that some irritation, itching or burning may occur on the skin if the bonding agent comes into contact with it. - I understand that if the bonding agent comes into contact with my eye, my eye will be flushed with water and I will be assisted in seeking medical attention immediately. - I understand that while every attempt will be made to provide me with the length and fullness I have chosen, my final result may not be what I initially envisioned. - I understand that it is imperative that I disclose all of the information requested in the Client Profile/Health History - I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications. - I understand that additional conditions could occur or be discovered during the procedure which could affect my ability to tolerate the procedure. - I consent to "before and after" photographs for the purpose of documentation, potential advertising and promotional purposes. - I give permission to my lash extension specialist to perform the lash extension procedure we have discussed, and will hold him/her and his/her staff harmless and nameless from any liability that may result from this treatment.

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LASH EXTENSION INTAKE FORM · Dove Esthetics - Paloma T. Pahle-Levesque