Name *

First Name

Last Name

Phone *

(###)

###

####

Due to COVID-19 and TDLR requirements please answer these questions to ensure that you will be able to come to your appointment. If you answered yes to any of these questions you will need to reschedule  your appointment. Reschedule via your appointment confirmation email. Please text 713-487-5107 reschedule  if online system doesn't allow.. *

Check any applicable

Have you traveled in or out of the country in the last 30 days?

Do you have or have you had a cough or fever in the last 14 days?

Do you feel ill or have you felt ill in the last 14 days?

Have you had or been exposed to Covid 19?

Not Applicable

Previous Issues or Allergies - Check All Applicable (If selected, you may not be a lash extensions candidate. Your stylist will check during your consultation). Bring Doctors Full Release form to proceed. Safety is our 1st concern. *

Allergic reaction to previous lash extensions

Allergies: (latex, acrylates, skin, eyes, etc.)

Asthma or any respiratory (breathing) problems

Medical conditions: (such as thyroid, alopecia, hair pulling, Trichotillomania, etc)

Recent eye infection

Recent eye surgery

Pregnant

None

Check All Applicable *

Able to lie on your back for 1-3 hours

Are you pregnant or planning to be

Prior eyelash extension procedure

Any allergic reactions to eyelash extensions

You wear contact lenses

You will remove your contact lenses

I Acknowledge sleeping on my face, water touching lashes within 24hrs, extreme weather changes, steam, sauna, and other activities may damage the adhesive or crimp the extensions and may require more frequent refills. I reviewed and understand the aftercare instructions and will do my part to help maintain my eyelash extensions. Aftercare directions are listed online at www.houstoneyelashes.com I understand that eyelash extensions require ongoing maintenance (similar to a nail rebase) and that refill fees are based on time and / or the number of extensions that need to be replaced at the refill appointment. If I wait too long between refills, I may need to pay for a new full set. If I no longer wish to wear the eyelash extensions, my technician will remove them and I will not try to remove them myself and there may be a fee for removal of the eyelash extensions. I understand that lash extension services have some inherent risk of irritation to the eye area, including the eye itself, and could result in eyelash loss, stinging, burning or swelling should an allergic reaction occur. You or your eyelash stylist may terminate the session anytime. I agree to reveal my history. I understand should some actions or conditions arise during the session it maybe ended. I acknowledge and understand there might be other known risks not reasonable foreseeable at this time. I agree to hold harmless, waive and release my stylist, Luxe Makeup & Lash Lounge LLC, partners, affiliates, contractors and linked company of any claim, liability, losses, injuries, damages, lawyer and court fees. I agree should a dispute arise it should go to arbitration in Houston and applies to all companies, contractors, stylist and Luxe. I release my stylist and Luxe Makeup & Lash Lounge LLC from any revealed or unrevealed pre-existing conditions. These services are being performed at my request and I take full responsibility for any adverse complications that may arise. I will seek medical care (at my own expense) and contact my Lash Technician immediately if any allergic or adverse reaction occurs. I understand the procedure and risks. I release Luxe Makeup & Lash Lounge LLC, affiliated companies and my Lash Technician from any and all liability associated with this procedure. Luxe Makeup & Lash Lounge LLC is not responsible for any Technician errors or misunderstandings. This procedure has many variables due to lifestyle, moisture, weather, extreme temperatures, natural eyelash shedding, and other factors. The Technician will assess and decide if I am a candidate for this service to the best of their ability. No guarantees are made or implied. *

Yes

Signature *

Typing your Name registers as your signature and acknowledgement.

First Name

Last Name

Date *

MM

DD

YYYY