CUSTOMER DATA PROFILE

Nombre: ____________________________________________________________
Phone: ______________________ Date of Birth: ____/_________/____
Mail: ____________________________________________________________
Address: ___________________________________________________________
City: _________________ State_______________________ C.P.: __________
Allergic to: _______________________ Skin Type: ______________________
Important medical conditions: ________________________________________
Person to call in case of emergency: __________________________________
Notes: ______________________________________________________________
___________________________________________________________________

How did you hear about us?

□ Urban □ Web search □Google □ Facebook □ Friend □ Anot
advertising Page her
________

You:
□ Lives in the area □ You are a visitor

Uses:
□ Eyeliner □ Masca □ Creams □ Strip tabs □ Eyelash Treatments Type
ra __________________

TÉCNICA: _______________________
DISEÑO: ________________________
CURVATURA: ____________________
GROSOR: _______________________
LARGO: _________________________
CHALLENGES:
DATE NOTES
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Please check if you have had any of the following conditions:
□ Alopecia (Absence or loss of hair in areas that normally have it).
□ Excessive growth of nails, hair, etc.
□ Eczema (a group of skin conditions that cause the skin to become red, irritated and itchy).
□ Conjunctivitis (Conjunctivitis causes itching and burning of the eyes).
□ Diabetic retinopathy (complication of diabetes and one of the main causes of blindness).
□ Glaucoma (characterized by increased pressure inside the eyeball).
□ Cataracts (partial or total opacity of the crystalline lens)
□ Epilepsy (a disease that causes sudden seizures, violent convulsions and loss of consciousness).
□ Diabetes (A disease in which there is an excess of glucose or sugar in the blood and urine).
□ Blepharoplasty (Eyelid Surgery)
□ Hypersensitivity to cyanoacrylate, formaldehyde or other bonding agents (fast-setting adhesives)
□ Trichotillomania (recurrent habit of pulling out one's own hair or hair from different areas of the
body).
□ Thyroid disease (This gland produces hormones that control metabolism).
□ Isotretinoin (Vitamin A, used in the treatment of acne and skin problems)
□ Psoriasis on the eye contour (appearance of red spots with whitish scales).
□ Chemotherapy Sensitive eyes or dry eye syndrome.
□ Laser eye surgery
□ Wear contact lenses
□ Major surgery in the last 120 days
□ Allergy to latex, synthetics, adhesives or plaster.
□ Seasonal allergies. Which seasons? ___________________________________________
□ Microdermabrasion (Peeling less aggressive than the common peeling)
□ Have any skin condition (Dermatitis, active acne, etc.)
□ Exposed to certain chemicals found in swimming pools such as chlorine, dye, dye.
□ Hormonal imbalance or stress.
□ Mental illness (schizophrenia, depression, bipolar, etc.)
□ How many times a week do you practice sports? _____________________________________
□ Otro __________________________________________________________
DISCLAIMER OF LIABILITY

I _______________________________________________________________ authorize Dulce Karen Ruiz

to apply Eyelash Extensions to my natural eyelashes and future Eyelash Extensions services such as
removal and touch up.
By signing this agreement I consent to the application, removal or touch-up of Eyelash Extensions by a
professional and to the following:
I understand that there are risks associated with artificial eyelashes and Eyelash Extensions applied to or
removed from my natural eyelashes.
In addition, I understand that as part of the procedure there may be eye irritation, eye pain, eye itching,
discomfort, and in some cases infection or blindness. I agree that, if I experience any of these medical
conditions with the synthetic eyelashes, I will contact the certified Eyelash Extensions professional and
he/she will have to remove the Extensions immediately and I will consult a physician at my own expense. I
understand that, even if the Certified Eyelash Extensions professional applies or removes the Extensions
using proper technique, the instruments, tapes, cleaning products, gel pads, adhesives and removers used
in the procedure may irritate my eyes and may require medical attention and follow-up and subsequent
removal of the eyelash extensions.
I understand and agree to the care instructions provided by the certified Eyelash Extensions professional
for the use and care of my Extensions. I am aware and agree that failure to follow these instructions may
cause the Extensions to fall off, become damaged and/or decrease in service life. I understand and agree
that my eyes will be closed and covered for the duration of the 120-180 minute procedure.
I understand that during the application I should not open my eyes to avoid irritation or poking the eye
with any extension or tool used in the process. I will not be able to get up, use my cell phone, or make
sudden movements. And in case of any particular discomfort or need during the application I will indicate
it verbally.

I agree to the following instructions for the maintenance of my Eyelash Extensions:

✓ Do not use waterproof mascara.
✓ Do not use eye drops of any kind.
✓ Do not use oil-based cosmetic products around the eyes.
✓ Do not wet the eye area for 48 hours after application.
Do not dye or curl the Eyelash Extensions.
✓ Do not constantly pull or rub the synthetic eyelashes.
✓ Maximum touch-up time is 25 days.

I am aware that my natural lashes have a life span of 30 - 60 days; therefore, I know that I will experience
shedding and the extensions will fall out.

This agreement will remain in effect for this procedure and all future procedures performed by the
Eyelash Extensions professional. I read in Spanish and understand that this consent agreement is legal and
binding. I have read and understand all the information contained in this agreement. I am over 18 years of
age and consent to the agreement and treatment.

I release my technician, the company and any and all persons representing this salon from all claims,
demands, damages, actions and cause of action arising out of the performance of service and procedure,
which is performed with utmost attention to safety and proper application, using tools and products that
the technician has been professionally trained to use.I release my technician, the company and any and all
persons representing this salon from all claims, demands, damages, actions and cause of action arising out
of the performance of service and procedure, which is performed with the utmost attention to safety and
proper application, using the tools and products that the technician has been professionally trained to
use.
There is no guarantee for the length of time the Eyelash Extensions will last longer than 30 days.
The company is not responsible for any technical errors. I understand the care instructions and will do my
part to maintain my Eyelash Extensions.
I understand that there are many factors that can affect the life of Eyelash Extensions, such as water,
contact with humidity, weather conditions and activities involving exposure to high temperatures or
sweating. I am aware that to make a touch-up valid I must have at least 40 extensions per eye if 15 days
have passed or 25 extensions per eye if 25 days have passed. I understand that the cost of retouching
depends on the amount of material to be spent.
By signing below, I verify that I have read and understand the above statements and agree to them.
I give my consent to take photographs of my eyes or face and the condition of my eyelashes before and
after the procedure and that these may be used for marketing purposes such as salon advertising and/or
marketing (website, brochures, business cards, salon or class, etc.).

Guarantee of application.
The guarantee is valid for the loss of 30% of eyelashes in the first application and 40% loss in touch-ups. I
understand that the warranty will not be valid if mascara, mascara applicator, oil, cream, cut, burned or
plucked eyelashes have been used. The warranty will NOT be valid AFTER 3 DAYS WITHOUT EXCEPTION.
And the warranty will be taken by photo evaluation or by attending an appraisal. In case of prepayment
there will be no refund for cancellation. All touch-ups or new appointments require a deposit of $______
to schedule.
All services performed must be paid for in full at the end of the application without exception. For
appointment changes, the salon must be notified 24 hours in advance. Otherwise any changes prior to
your appointment will be penalized with a $100 fee, which will be taken from the set aside deposit. The
tolerance time is 10 min without exception.
Loyalty cards are only valid for recurring touch-ups.
After 10 applications, a complete removal and new application of the set will be made without any
exception.
All the material used is hypoallergenic, in case of any allergy or discomfort will be the client's own
condition, which must be treated with your doctor, the salon is not responsible for any expenses that this
may cause.

The application, touch-up and removal of eyelash extensions may require the following materials and/or
tools:
Silk polymer eyelash extensions (different curvatures, lengths and thicknesses), Medical Surgical Grade
Eyelash Extensions Adhesive, Eyelash Extensions Adhesive, Removal Gel, Removal Cream, Sealer, Micro
Brush, Sanitizing Gel, Mircopore Tape, Tool Cleaner, Collagen or Hydrogel Patch, Cotton, Swab, Disposable
Towel, Makeup Remover, Eyelash Impurity Cleaner, Wooden Stick, Mouthpiece, Gloves, Surgical Cap,
Goggles, Glasses, Eyeglasses, Eyeglasses, Eyeglasses, Eyeglasses, Eyeglasses, EyeglassesSwab, Swab,
Disposable towel, Make-up remover, Eyelash impurity cleaner, Wooden stick, Mouth cover, Gloves,
Surgical cap, Glasses, Separating forceps, Placement forceps, Jade stone, Adhesive ring, Intraoral mirror,
Fine tip manicure scissors, Lens with magnifying glass, Eyelash organizer board.
It is recommended to use LASH SHAMPOO to have a constant and deep cleaning, which will help my
extensions to have more durability and avoid infections.
When I leave my appointment, I will have to wait a minimum of 24 hours before I can get them wet. I am
aware that the first few contacts with water, the adhesive reactivates and may cause a slight stinging for a
minute or two, which is completely normal.

I certify that I have fully understood, read the aftercare instructions and will comply with the above as
outlined in this contract and in the Eyelash Extensions Aftercare Guide I have received.
Client Name ______________________________________________________.
Signature _____________________________________ Date ________ /____________________ / 201__.
CONFIDENTIALITY NOTICE

In accordance with the provisions of the Federal Law for the Protection of Personal Data in Possession of
Individuals and its Regulations, we inform you that we are responsible for the collection of your personal
data, the use given to them and their protection.
Your personal information will be used to provide you with the health services offered by
_________________________________________ treatments that you have requested, to inform you
about conditions and changes in them and to evaluate the quality of the service we provide.

For the aforementioned purposes we need to obtain the following personal data: Name, Address,
Telephone, Email.
We collect your personal data for the purposes mentioned in this Privacy Notice. In this sense, we inform
you that your personal data will be treated and safeguarded based on the principles of legality, enshrined
in the Federal Law on Protection of Personal Data Held by Private Parties and its Regulations.

We request your consent through this Privacy Notice in order to use them for the following purposes:
1. In order to perform the aforementioned services that you have entrusted to us.
2. Identify you as a customer and provide you with the services contracted with us.
3. To contact you and send you relevant information regarding our services.
We inform you that your personal data will be safeguarded under strict administrative security measures,
which have been implemented in order to protect your personal data against unauthorized use, access or
treatment.
As the owner of the personal data subject of this Privacy Notice you may exercise your rights of access,
rectification, cancellation or opposition (ARCO Rights), you may also revoke the consent granted for the
use of your personal data in any of these cases, you can make your request by sending an email to the
address psic.karenruiz@gmail.com, telephone 3313034325 or visit our Facebook page
______________________________________.
In order to be able to attend your request, it must meet all the requirements stipulated in the Federal Law
for the Protection of Personal Data in Possession of Individuals and its Regulations.
This Privacy Notice may be amended from time to time. In any case, any modification will be made known
to you by sending an e-mail to the account you initially provided us with and/or by posting it at our
address above.
Date of last update January 01, 2016. We will not be liable in the event that you do not receive such
notice of a change to the Privacy Notice because of a problem with your e-mail account or Internet data
transmission. However, for your security, the current Privacy Notice will be available at all times at the
above address. If you DO NOT express your opposition to the transfer of your personal data, it will be
understood that you have given your consent to do so.
□ If I consent to the transfer of my personal data under the terms of this privacy notice.
Client's name: __________________________________________________
Firma ____________________________
CARE BEFORE YOUR APPOINTMENT

- AVOID WEARING CONTACT LENSES DURING THE PROCEDURE.

- AVOID CURLING THE EYELASHES ON THE DAY OF APPLICATION.
- ARRIVE 10 MINUTES BEFORE YOUR APPOINTMENT TIME FOR YOUR CONSULTATION.
- NOT TO TALK ON THE PHONE.
- DO NOT CHEW GUM DURING APPLICATION.
- REMOVE MAKE-UP FROM THE EYE AREA, INCLUDING EYELINER, EYE SHADOW, EYE CREAM, ETC.
- THE CUSTOMER SHOULD NOT WET THE EYELASHES 24 HOURS AFTER APPLICATION.

AFTERCARE

It takes 24 hours for the adhesive to dry completely, the following activities will cause faster lash loss and
should be avoided.

- Bathing (within the 24-hour period)

Exposure to high temperatures and/or saunas.
- Eye carving
- Application of oil eye make-up
- Sleeping on the stomach.
- Receive facial treatments
- Use Mascara

It is necessary:
Wash the eyelashes in the morning and at night with a special Shampoo and brush.
Comb the eyelashes with the brush supplied with your application.
Go for touch-ups punctually every 15 to 21 days (after 21 days it is considered a new application).

Important note; the only elements that will cause the loss of eyelash extensions no matter how carefully
they are cared for.
*HUMIDITY
*ACEITE
*SALT WATER