Client Intake Form

Get ready for your appointment with Rosy Fernandez!

First Name *

Last Name *

Phone *

Email *

Address *

City *

State *

Postal code *

Date of birth *

Must be in MM-DD-YYYY format to avoid error

+ Let me know who, so I can send them some love! 🤍 *

+ Please elaborate, so we can track our marketing efforts! *

+ What's your Instagram handle? *

Emergency Contact Name: *

Emergency Contact Phone Number: *

Do you wear: *

Glasses

Daily Disposable Contacts

Extended Wear Contacts

None of the Above

How would you describe your hair growth? *

Fast

Slow

Not Sure

Do you have a tendency to rub or pull on lashes or brows? *

Do you exercise regularly? *

List all current medications, herbal supplements, and vitamins: *

Do you have any type of nutrition restrictions? *

Yes

Are you allergic to any of the following? *

lash, nail adhesive or dermabond (surgical glue)

tape (ex: bandages)

long-lasting or waterproof cosmetics

topical cosmetic ingredients

none that I know of

Please explain any other allergies you are aware of:

What service are getting? *

Lash Extensions

Lash Lift & Tint

Brow Lamination

Waxing or Sugaring

Have you ever had Lash Extensions? *

Yes

Have you ever had a Lash Lift and/or Tint? *

Yes

Have you ever had a Brow Lamination? *

Yes

Do you have any Eyelash Extensions on now? *

Yes

When did you last have it done? *

When was your last Lash Appointment? *

2 weeks ago or less

Between 2-3 Weeks

Over 3 Weeks

Over 4 Weeks

Did you have any adverse reactions? Please explain: *

Terms & Conditions

Please read and acknowledge the following to indicate that you have read and understood tAhe terms and conditions.

Before & After Photo Documentation *

You may use my documentation in your portfolio

Please do not use my doumentation photos

Eyelash Extension Home Care *

I understand the longevity of my eyelash extensions requires my careful maintenance.

I understand that basic makeup application and normal lifestyle can resume after the application.

I understand that touching my lashes with my fingers, sleeping on my stomach, and using oil based products or products not designed for use with extensions around by eyes can weaken my lash bonds and cause premature extension fallout and/or irritation.

Home Care *

I understand the longevity of my lash lift, tint and/or brow lamination requires my careful maintenance.

I understand that I must refrain from contact with water or steam for 24 hours following the service.

I understand that basic makeup application and normal lifestyle can resume after 24 hours.

Late & Cancellation Fees *

I understand that rescheduling or cancellation requires a 24 hour notice to avoid a 50% service charge.

I understand that no shows are charged 100%.

I authorize Rosy Fernandez to perform the services I have specified that I am here for. I understand that it is my responsibility to be still during the process until otherwise advised. I have been fully informed as to the methods and procedures concerning the services. The risks of the cosmetic service/procedure I have chosen have been disclosed to me. Some cases may result in complications, such as transient eye redness, skin irritation or allergic reaction to the medical-grade adhesive or any other products used. If at any time I feel uncomfortable with the procedure, I will inform the stylist who will gladly rectify the problem, including ending the session if I (or the stylist) wish. It has been represented to me that no guarantees, warranties, promises, commitments or other statements as to the results of this service have been made. I acknowledge that I have received no particular representations or guarantees, and I am consenting to the procedure at my own risk. I have revealed or disclosed on the form above, all conditions and circumstances regarding my health and health history, medications being taken and any past reactions to products used or medications taken. Additional conditions could occur or be discovered during or after the procedure, which could affect my ability to tolerate the procedure.

I release, give up, acquit and discharge Rosy Fernandez and/or anyone affiliated including any partnership, corporations or company associated with said individual from any claims or damages of any nature. I agree to pay any costs of legal services necessary to further effector confirm said release. I further agree that this release shall be in contemplation of any possible damages, either known or unknown at the signing of this waiver and release form, and said damages are specifically waived following the signing of this waiver and release form. I further agree that in the event any litigation ensues, it shall be placed before the American Arbitration Association for resolution. I agree that in the event a decision is determined in favor of one party over the other, the prevailing party shall be entitled to reasonable attorney fees and costs as set by the arbitrator. I further agree to hold Rosy Fernandez nameless and harmless from any and all damages. I release Rosy Fernandez from any responsibility for pre-existing conditions I have not revealed, or any consequential change to those conditions that arises subsequent to the procedure. I understand that I am responsible for any medical treatment I may need to receive as a result of getting this procedure. I accept full responsibility for these and any other complications, which may arise or result during or following the eyelash extension service(s), which are to be performed at my request.

I certify that I have read and fully understand the above waiver and release form. I certify that I have consulted with Rosy Fernandez and have had all of my questions answered. I accept the explanation of potential complications and risks described herein. I certify I am of sound mind, and I am fully capable of executing this Waiver & Release form for myself. I acknowledge and fully understand that there might be other unknown risks not reasonably foreseeable at this time.

Effective January 1, 2022 all credit card payments will include a 4% service charge. Cash or other electronic payments are welcomed.

Signature

Clear