Lash Extensions Consent Form

Oregon Administrative Rule (OAR) requires that an esthetics certification holder providing esthetic services be responsible for collecting and maintaining copies of client records. (OAR 817-015-0065)

Date
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Name
First Name

Last Name

Phone Number
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Email

Address

Date of Birth
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Any medications:

Other relevant information:

Information/Last done on:

AGREEMENT: I request and consent to these procedures being carried out today without undergoing a sensitivity patch test. The sensitivity test, which if conducted may indicate my sensitivity / allergy to the products. I understand the contents of this form and take full responsibility for my actions, thus absolving all other parties of their responsibilities, if any, associated with the supply of the products and services(s).
print full name

Date
MM

DD

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PHOTO RELEASE: I give my permission to use my image, and/or appearance as such may be embodied in any pictures, photos, video recordings, digital images, and the like, taken or made on behalf of Mai Berg Artistry, LLC. I agree that Mai Berg Artistry, LLC has complete ownership of such pictures, etc., including the entire copyright, and may use them for any purpose consistent with Mai Berg Artistry, LLC mission. These uses include, but are not limited to illustrations, bulletins, exhibitions, videotapes, reprints, reproductions, publications, advertisements, and any promotional or educational materials in any medium now known or later developed, including the Internet. I acknowledge that I will not receive any compensation, etc. for the use of such pictures, etc., and hereby release Mai Berg Artistry, LLC and its agents and assigns from any and all claims which arise out of or are in any way connected with such use.
I have read and understood this consent and release.

I authorize MAI BERG ARTISTRY LLC and all of their associates to provide and apply the following services and or services: semi-permanent eyelash extensions/ brow henna/ lash & brow lift & tint/lash extension removal. In order to minimize risk of injury, I understand that it is my responsibility to lie or sit completely still for the entire procedure or until otherwise directed by the technician. I have been fully informed regarding the methods and procedures used in the application and aftercare recommendations.
All risks and potential complications, including but not limited to, redness, irritation, and allergic reactions to either the adhesive, eye pads, or any other products used have been fully disclosed to me. I certify that I understand these risks and potential complications, and that I knowingly and voluntarily consent to the application or removal for any of the services listed above. If at any time I feel uncomfortable during the procedure, I agree to immediately notify the the technician. The technician will see to remedy the problem, including ending the session if it is deemed prudent by the technician. I acknowledge that no guarantees or promises regarding the appearance or longevity of the eyelash extensions, henna brows, or lash tinting. I herby certify that I have disclosed all conditions regarding my health history, and past reactions to products, treatments and medication I am currently or recently using.

I understand and consent to having my eyes closed and covered for the duration of up to 3 hour procedure. Times may vary depending on the type and number of eyelashes applied
Yes

No

I understand that in rare occasions there are risks associated with having artificial eyelashes and eyelash extensions applied to or removed from my natural eyelashes. I further understand that in rare cases as part of the procedure eye irritation and discomfort could occur. I agree that if I experience any of these conditions with my lashes that I will contact the certified eyelash extension professional that performed this procedure and it may be beneficial to have the eyelashes removed.
Yes

No

I acknowledge that the natural lash cycle is 60 to 90 days. When one lash falls out, there is another lash growing in. I, therefore, understand that I will need regular fills, every 1 to 3 weeks, to keep my lashes looking beautiful and full. I understand that variables, including the natural lash cycle and home care, will influence the longevity of eyelash extensions.
Yes

No

Thank you!

Lash Extensions Consent Form

MAI BERG ARTISTRY

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