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Bare Envy Registration
Full Name
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Email
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Phone
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How did you hear about us?
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Google
Social Media
Other
Referred By
New Clients - It is highly recommended to book a patch test 36-48 hours prior to your appointment to test for allergic reactions or sensitivities. Would you like to book a complimentary patch test?
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Yes
No
Please check all that apply to you:
Laser Eye Surgery
Regular exposure to chemicals
Alopecia (hair loss)
Seasonal Allergies
Allergies to synthetics
Eating disorders (causing hair loss)
Allergies to adhesives
Recently treated for eye injury
Dry eyes
Diabetic
Microdermabrasion
Chemotherapy
Sty or Cyst
Blepharitis
Conjunctivitis
Lifestyle Information:
Are you currently wearing eyelash extensions?
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Yes
No
Have you had a lash perm/tint in past 6 weeks?
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Yes
No
Are you pregnant or breastfeeding?
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Yes
No
Have you had any type of eye surgery within the last year?
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Yes
No
Do you have frequent eye irritation, itching, or watery eyes?
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Yes
No
How do you sleep at night?
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Back
Left Side
Right Side
Stomach
Do you wear strip lashes?
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Yes
No
Do you use an eyelash curler/heater?
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Yes
No
Do you use mascara?
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Yes
No
Do you use eye cream/gel?
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Yes
No
Are you wearing contact lenses now?
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Yes
No
Do you have any other medical conditions we should be aware of prior to performing your treatment?
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Yes
No
Why do you want this treatment?
Daily wear
Special occasion
Other
New Client Consent Form
Please initial at each line and sign at the bottom.
I understand that there are risks associated with eyelash extensions and eyelash lifts.
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I understand and agree that if I experience any of these issues with my lashes I will contact my technician and have the eyelash extensions removed immediately (if necessary) and consult a physician at my own expense.
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I understand that I will need to keep my eyes closed for a duration of 60-180 minutes during the procedure. I also understand that I will need to be lying in a reclined position. Any medical conditions that might be aggravated by lying still for a prolonged period of time may mean that I will not be able to have the procedure performed on my eyes.
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This agreement will remain in effect for this procedure and all future procedures conducted by my technician or any other technician conducting business at Bare Envy. I understand that this agreement is binding and that I have read and fully understand all information above. I represent that I am over the age of 18 years. If below 18 years of age a parent or guardian must also sign this form.
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By booking this appointment, you agree to a cancellation fee of 50% of the service value should you cancel less than 24 hours from the time of your appointment. You will be charged 100% of the service for a NO-SHOW or a cancellation less than 1 hour from the time of your appointment. **Exceptions may apply for COVID-19 prevention**.
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I understand that as part of the procedure, eye irritation, pain, itching discomfort and in rare cases eye infection may occur.
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I understand and agree to follow the aftercare instructions provided by my technician. Failure to follow the aftercare instructions may cause an unsatisfactory result.
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I give permission for Bare Envy to take photos or videos recordings that may then be used for social media, web-site, promotional, and educational use. I understand that my image may be edited, copied, exhibited, published, or distributed, and waive the right to inspect or approve the finished photo/video wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording.
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I release my technician from all liability associated with this procedure. Bare Envy is not responsible for any technician errors. I understand that I have been advised to follow the aftercare protocol from my technician so as to avoid any discomfort or adverse side effects after the procedure has been completed.
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REFUND POLICY: If you have concerns with a service you received, please contact us within 48 hours. No refunds are offered on eyelash services. If you have an allergic reaction to a service we provided, a removal will be offered free of charge.
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By signing below, I verify that I have read and understand the above statements and agree to them.
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Date / Time
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Name
Submit
