Name *

First Name

Last Name

Date of Birth *

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Today's Date *

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Phone

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Please select all that apply to you *

I wear contacts

I take fish oils

I am allergic to latex, adhesives, or cyanoacrylates

I have/had cancer

I have/had eye injury or illness

N/A

Please read carefully and check all for understanding *

You must check all of you will not receive service from Kreem Pink Box.

I understand this procedure requires single synthetic lashes to be glued to my own natural lashes.

I understand that it is my responsibility to keep my eyes closed and be still during the entire procedure, until my eyelash technician addresses me to open my eyes.

I understand that some risks of this procedure may be but not limited to eye redness and irritation. The fumes from the adhesive may cause my eyes to tear up if I open my eyes.

I agree to disclose any allergies that I may have to latex, surgical tapes, cyanoacrylate, Vaseline, etc..

I understand that I am required to follow the eyelash aftercare sheet in order to maintain the life of these lashes.

I agree that by reading and signing this consent form, I release Kreem Pink Box and any of its employees/agents from any claims or damage of any nature

I agree that I read and fully understand this entire consent form.

I am of sound mind and fully capable of executing this waiver for myself.

I have read and understand Kreem Pink Box policies.

I have read and completed the Eyelash Extensions Intake & Consent form in its entirety, and have answered everything to the best of my ability.

I have been informed of potentially harmful or negative side effects that may be caused by the application and/or removal of Eyelash Extensions.

I confirm and agree that I wish to engage the services of Kreem Pink Box to apply eyelash extensions. *

First Name

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