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MIRAGE Salon & MedSpa
I certify that I am a competent adult of at least 18 years of age
I certify that I am a minor under the age of 18 and understand that the consent of my parent/legal guardian will also be required before treatment.
I agree to have eyelash extensions applied and/or removed from my eyelashes. Before my qualified eyelash extension professional technician can perform this procedure, I understand I must complete this agreement and provide my consent by signing where indicated below.*
In order to have my eyelash extensions applied and/or removed from my eyelashes by Mirage Salon & MedSpa, from hereafter referred to as the professional technician, I agree to the following by checking each statement:
I understand there are risks associated with having artificial eyelashes applied to and/or removed from my natural eyelashes. I understand, as a result of the procedure,I may experience eye irritation, eye pain, eye itching or discomfort. In rare instances, eye infection or permanent damage to eyes could occur.*
I agree that if I experience any of the aforementioned reactions as a result of my eyelash extension procedure that I will contact my professional technician and have the eyelashes immediately removed and consult a physician at my own expense.*
Even though the professional may apply or remove the eyelashes properly, I understand that adhesive material may become dislodged during or after the procedure, which may irritate my eyes or require further follow-up care.*
I agree to follow the care instructions provided by the professional for the use and care of my eyelash extensions. Failure to follow the care instructions can cause the eyelash extensions to fall out, damage the extensions and/or decrease the life, appearance, and quality of the eyelash extensions.*
I agree to inform my professional of the following information if it applies to me:
I wear contacts. If I wear contacts, I agree to remove them prior to the eyelash extension procedure.
I am allergic to any type of adhesive. If I am allergic to adhesive, I will not be able to wear extensions.
I am claustrophobic. If I am claustrophobic, I may not be able to have the eyelash extensions applied.
I recently underwent chemotherapy. Therefore, I will not be able to wear eyelash extensions.
Prior to my appointment, I understand the following instructions should be followed:
No waterproof mascara
No oil based products around the eye area
No water to come in contact with the eye area within 24 hours of the eyelash extension and/or touch-up procedure
No tinting or perming of the eyelash extensions
No continuous rubbing or pulling on the synthetic lashes
I understand that in order to have the lashes applied to my natural eyelashes, I will need to keep my eyes closed for duration of 60-90 minutes during the procedure. *
I also understand that I will need to by lying in a reclined position. *
I agree to inform the professional of any medical condition that might be aggravated by lying still for a prolonged period of time. The eyelash extension application will not be performed if any medical condition may be aggravated by the procedure.*
I understand this agreement will remain in effect for the procedure, and all future procedures, conducted by the eyelash professional technicians at:
Mirage Salon & MedSpa, 2208 Taylor Avenue, Norfolk, NE 68701*
I understand that this agreement is binding and that I have read and fully understand all information listed above.*
I consent to allowing Mirage Salon & MedSpa to use the photographs on their social media for promotional purposes.