KYR8 BEAUTY Procedure Consent Form
Please complete applicable fields prior to your scheduled appointment.
First Name
Last Name
Email
Phone Number
Do you have any known allergies or sensitivies?
Select an option
Yes
No
If YES, what are they?
60
Client Medical History - Generally Related to the Eye *Check all that apply.
Eye Surgery, Infection, or Injury to Eye Area (0-6 Months)
Chronic Dry Eye
Seasonal Allergies or Frequent Irritation (Itchy, Watery Eyes)
Permanent Eye Makeup (0-8 Weeks)
Blepharitis (Inflammation of Eyelids)
Allergies to Cyanoacrylate Adhesives (i.e. Surgical Glue, Nail Glue, Crazy Glue)
Hypersensitivity to Formaldehyde (A by-product released in Cyanoacrylate Adhesives)
Retinoids Used to Treat Acne and Skin Problems (such as Accutane or Retin A)
Epilepsy Triggered by Photosensitivity
Client Medical History - Generally Related to the Eyelashes *Check all that apply.
Hormonal Imbalance
Recent Severe Illness or Injury
Pregnancy or Recent Childbirth
New or Recently Prescribed Contraceptives (Oral, IUD, hormonal, etc.)
Medical Conditions that May Contribute to Hair/Eyelash Loss (Alopecia, Lupus, Diabetes)
Vitamin or Mineral Deficiencies that May Contribute to Hair/Eyelash Loss (A, F, B, Zinc, Iron)
Hypersensitivity to Formaldehyde (A by-product released in Cyanoacrylate Adhesives)
Retinoids Used to Treat Acne and Skin Problems (such as Accutane or Retin A)
Trichotillomania (Hair Pulling Disorder)
Medications that May Contribute to Hair/Eyelash Loss (Chemotherapy, Anticoagulants, Beta Blockers
Any Metabolic or Endocrine Disorder
Have you had eyelash extensions applied before?
Select an option
Yes
No
If YES, why did you remove them?
Select an option
Natural Fall Out (6-8 weeks)
Irritation/Discomfort
Poor Retention (Pre-mature shedding)
Allergic Reaction (Redness accompanied by swelling, burning sensation, abnormal discharge)
Took a Break
In-Need of Removal
If YES, how did you remove them?
Select an option
Natural Fall Out (6-8 weeks)
Professional Removal
Self-Removal (Picking, At-Home Adhesive Removal)
Other
Do you wear glasses or contacts?
Select an option
Yes
No
Eyelash extensions require medical tape and adhesives that may contain acrylic or latex. Are you allergic to any medical tape, latex, or acrylic?
Select an option
Yes
No
Have you had nail enhancements (acrylic/gel) before?
Select an option
Yes
No
If YES, why did you remove them?
Select an option
In-between Appointments
Poor Retention (Lifting, chipping, cracking)
Desired a New Full-Set
In-Need of Removal
Other
If YES, how did you remove them?
Select an option
Professional Removal
Soak-Off
Peel-Off
Other
Heat-spiking sensation may occur from gel enhancements. Do you have a physical photosensitivity to UV lighting?
Select an option
Yes
No
Not Sure
I understand that eyelash extensions and nail enhancements are semi-permanent; lasting effects are highly variable and dependent upon a number of factors.
Factors include skill set and expertise of the technician, my normal growth cycle, use of cosmetics and skin care products, and adherence to the instructions for maintenance and care.
I have been given the opportunity to ask questions about the products, application procedure, and any risks involved.
The above information is truthful to the best of my knowledge. I do not have any known conditions, allergies, or unusual sensitivities or have listed them above.
I understand touch-up/refill appointments may be necessary for an additional cost.
I hereby authorize Kyra Ellis-Cairns to perform services rendered on me at my request. In the unforeseeable event of an allergic reaction, Kyra Ellis-Cairns of KYR8 BEAUTY will not be held responsible under any circumstance.
I acknowledge all services are non-refundable.
Your Signature
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