General Lash Waiver Electronic

Thank you for choosing The Standard Aesthetics for your eyelash extensions. This form must be completed prior to your service. Thank you!

Please fill your name: *

Please enter your full name.

Please Enter Date *

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Please fill in Address: *

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Phone number: * Please enter your phone number.

Email: * Please enter your email.

Date of Birth: *

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Have you ever worn lash extensions before? *

Yes

Please select at least one choice above.

If so, what brand? If you’re unsure, you can say unsure. * Please enter your answer here.

What was your experience like with these extensions or what did you like/dislike about them? * Please enter your answer here.

Are you allergic to medical tape? *

Yes

Not Sure

Please select at least one choice above.

Are you allergic to medical adhesives such as Liquid Stiches, Dermabond, etc? *

Yes

Not Sure

Please select at least one choice above.

Do you suffer from seasonal allergies? *

Yes

Please select at least one choice above.

Do you consider your eyes sensitive? *

Yes

Please select at least one choice above.

Have you had eye surgery in the past month? *

Yes

Please select at least one choice above.

What are you hoping to achieve today with your extensions? (Circle all that apply) *

Length

Volume

No More Mascara

Curl

Wing/Cat Eye

Drama

Believable

Other (if other, please fill out below)

Please select at least one choice above.

Other: Please enter your answer here.

How did you hear about us? * Please enter your answer here.

Where have you seen us? *

Internet (Facebook/Instagram)

News Article

Salon

Friend (Referral)

Other (if other, please fill out below)

Please select at least one choice above.

Other: Please enter your answer here.

If referred, by whom? Please enter your answer here.

Your privacy is valued. The information you provide is not disclosed and will never be shared with entities outside our place of business.

Your information is used ONLY for internal statistic, marketing and information purposes. You will not receive bulk or spam email messages. You may, on occasion, receive email when special offers, price changes, or important issues arise.

Please read and discuss each statement with your Certified Eyelash Extensionist, then initial next to each one.

Initial Here

I agree to only use recommended products on my eyelash extensions and have been advised that the use of other products can shorten the length of time my extensions remain in place. * Please click the yellow area and provide your initials here.

Initial Here

I understand that there are many variables, including technician expertise, lash growth cycle, use of cosmetics and skin care products, sleep habits, and the overall care given that will influence how long my extensions remain in place. * Please click the yellow area and provide your initials here.

Initial Here

I acknowledge that I should not rub my eyes or pull on my lashes after my extensions have been applied. * Please click the yellow area and provide your initials here.

Initial Here

I have been advised that using any mascara or heavy eye makeup including shadows and liners on a regular basis can shorten the length of time my extensions remain in place. * Please click the yellow area and provide your initials here.

Initial Here

I have been advised that waterproof mascara, “oil-free” products, or products containing glycols should never be used on my extensions. * Please click the yellow area and provide your initials here.

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I understand that this procedure does not require the breaking of my skin, therefore the contraction of any blood borne pathogens is not possible. * Please click the yellow area and provide your initials here.

Initial Here

I understand that touch-up appointments will be necessary every 2-4 weeks and that will be additional fees for this procedure. I also understand that if I wait longer than the recommended amount of time to come in for a touch- up appointment, additional fees on top of the normal fees may apply. * Please click the yellow area and provide your initials here.

Initial Here

I have been made aware of the possibility of an allergic reaction and how to recognize the symptoms. I have been advised that in such a case of an allergic reaction that visiting my primary physician or optometrist is the best course of action. I have been given the option for a patch test prior to extension application. * Please click the yellow area and provide your initials here.

Initial Here

I have discussed the differences between Novalash Platinum Bond Adhesive and the Sensitive Eyes Adhesive with my Certified Eyelash Extensionist and have made the decision myself on which adhesive I would like to use. * Please click the yellow area and provide your initials here.

Initial Here

I understand that a certified eyelash extenionist does not apply eyelash extenions properly, there is a risk of eye damage and harm to my vision. * Please click the yellow area and provide your initials here.

Initial Here

I understand that if I do need to have my eyelashes removed for any reason there is a removal fee, cost may vary * Please click the yellow area and provide your initials here.

Photo Release Consent
This section is OPTIONAL.

By signing below, you are granting permission for employees of The Standard to take photos of your eyes/face which may be used for marketing or educational purposes on websites, social media, in salon, or a class. Please circle one of the following, then sign and date your consent.

Photos of Eyes Only

Photos of Entire Face

Please select at least one choice above.

Eyelash Extensions are not for everyone. Prior to application, you should notify and discuss with your Certified Eyelash Extensionist if you experience any of the following:

⦁    Unusual sensitivity or skin reaction to Cyanoacrylate-based adhesives. (liquid stitches, Dermabond, Super Glue, etc.)
⦁    Moderate to severe allergies in combination with abnormal eye discharge.
⦁    Any eye disease or medical condition such as Conjunctivitis (pink eye).
⦁    A compromised immune system due to cancer treatment, hepatitis, or advanced AIDS.

⦁    Any type of cancer
⦁    Alopecia
⦁    Skin disease
⦁    Any metabolic or endocrine disorder.
⦁    Blunt trauma in or around the eye area.
⦁    Intoxication or impaired motor skills due to medications, alcohol, or any other drug.

Never allow uncured cyanoacrylate-based adhesives or removes to contact the eyelid or eyeball. Any uncured cyanoacrylate-based adhesive or remover in contact with the eyelid or eyeball may cause temporary or permanent damage including temporary or permanent loss of or blurred vision. For any reason, if uncured cyanoacrylate adhesive or remover contacts the eye area, immediately flush with large amount of water and seek immediate medical attention. Additional information may be found in the Material Safety Date Sheet (MSDS) with The Standard is happy to supply a copy or upon request.

Tips for Maintenance and Care

To maximize the length of time your Eyelash Extensions remain in place, we recommend the following:

⦁    Only a Certified Eyelash Extensionist should apply eyelash extensions.
⦁    Use only recommended cosmetics and cleansers (including Novalash Aftercare products and excluding glycol-containing products) after extensions have been applied.
⦁    Do not rub your eyes or pull on the lashes after eyelash extensions have been applied

⦁    Avoid using mascara on a regular basis.
⦁    Do not use waterproof mascara or “oil-free” products on your Eyelash Extensions.
⦁    After the application, come in for regular tough-up appointments as recommended by your Certified Eyelash Extensionist.

Consent for Procedure

⦁ I have fully read, discussed, and understood all of the information on this form. I have been given the opportunity to ask questions about the products, the application procedure, and any risks and hazards involved.

⦁ My Certified Eyelash Extensionist has fully explained the procedure and answered all of my questions and addressed all of my concerns to my satisfaction. I have sufficient information to give informed consent to the procedure.

⦁ I do not have any condition as noted above, or any other condition, which I am aware, that would affect the general use or application of eyelash extensions.

Time is very valuable here at The Standard to ensure that all clients are provided with the best look possible. For this reason, we please ask that you be on time to all of your appointments. We also ask that you thoroughly clean lashes prior to your extension tough-up appointments. We understand that life happens and if you need to clean your lashes before your appointment begins you may ask the front desk or an available employee to supply you with Novalash CleanLash Makeup Remover Pads and/or a mild soap and direct you towards the sink where you can clean your lashes and prepare for your appointment. Please try to arrive 10 minutes prior to your scheduled appointment time in such a case.

In the event that you should be tardy, we please ask that you be considerate and call to inform us of your situation so that we may take necessary action or make special arrangements accordingly. Please be aware that if you are late to your appointment, full results cannot be promised. Please also be aware that if you are 15 minutes or more overdue you may need to reschedule your appointment.

In the event that you need to cancel or reschedule your appointments we ask that you please notify us before 24 business hours before your scheduled appointment time. At The Standard, we like to enforce a strict but reasonable policy. We understand that an occasional missed appointment due to unavoidable events can happen. However, the final decision of the following strictly enforced policy is up to your Certified Eyelash Extensionist by signing this form you have read, understand, and agree to comply with our policy.

⦁ WE RESERVE THE RIGHT: to charge 50% of the scheduled service price when cancelling or rescheduling “the day of” your appointment.
⦁ WE RESERVE THE RIGHT: to charge 100% of the scheduled services on “no-shows”.

The satisfaction of our clients in our main priority. We offer prompt solutions to any problems or concerns occur.

Unfortunately, we do not offer refunds, credits, or exchanges for products sold or services rendered.

If for any reason you feel dissatisfied with our services, please bring this management’ attention. We appreciate all feedback, negative or positive, from our clients to better serve you. As part of our service we like to provide follow-ups, by phone or email, for any questions or concerns.

Thanks you for your business in advance.

By signing below, you are stating that you have read and discussed the contents of this page with your Certified Eyelash Extensionist and that you comply with the policies enforced.

Your signature *

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Your Name * Please enter your answer here.

Signature Date *

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Eyelash shopkeepers tend to use waiver electronic splash script.