Please Print This Form, Fill It Out, & Bring To Your Appointment
Name ____________________________________________ Date _____-_____-_____
Address _____________________________________________________________________
Telephone No. ( ___ ) _______-___________ Cell No.( ____ ) _______ - ____________
Email Address: please print clearly _______________________________________________
How did you hear about this service? ______________________________________________
Name of person who referred you. 1ST & Last Name__________________________________
((( RELASE OF LIABILITY ))) Please sign name in appropriate spaces
I understand that there are risks associated with the use of eyelash adhesive, eyebrow waxing, and/or eyebrow bleach/tint in the eye area. By choosing to receive eyelash and/or eyebrow services, I am assuming all risks associated with the use of chemicals & adhesives needed to complete the services.
I __________________________, AGREE TO ACCEPT ANY CHEMICAL SERVICES & AGREE TO INDEMNIFY & RELEASE FROM ANY LIABILITY INJURIES I MAY RECEIVE AS A RESULT OF SERVICES RENDERED BY PAMELA Taylor-PREVETT / LASHVILLE LASHES.
Lashville Lashes / Pamela Taylor - Prevett will not be responsible for any further hair loss or damages caused by the eyelash adhesive. If client decides to take further legal actions, you will be responsible for attorney & court fees. FILL IN THIS BLANK ONLY IF YOU ARE WILLING TO BE A MODEL. I ___________________, agree to be a before & After Shot Model used for website marketing materials-but not limited to.
Please Place A (Ö) Beside The Service(s) Provided
( ) Eyebrow Razor Arch . . . . . . . . . . . . . . . . . . . . . . $10.00
( ) Eyebrow Threading . . . . . . . . . . . . . . . . . . . . . . . $20.00
( ) Threading Of Lip . . . . . . . . . . . . . . . . . . . . . . . . . .$20.00
( ) Threading Of Cheeks / Neck . . . . . . .$30.00 per section
( ) Threading Of Chin Only . . . . . . . . . . . . . $15.00
( ) Eyebrow Wax . . . . . . . . . . . . . . . . . . . . $15.00
( ) Facial Wax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $13.00 & up
( ) Eyebrow Tint . . . . . . (darken) . . . . . . . . . . . . . . . $25.00
( ) Eyebrow Bleach . . . . . (lighten) . . . . . . .$20.00
( ) Eyebrow Tweeze . . . (tweezers only) . . . . . . . . . .$35.00
( ) Makeovers / Cosmetiks . . . . . . . . . . .$60.00 & up / Weddings . . . . . $80.00
( ) False Eyelashes / Individual Flares. . . $25.00 & Up
( ) Individual Flares Fill Ins . . . . . . . . . . . . $10.00 & Up
( ) False Eyelashes / Individual Singles . .$75.00
( ) False Eyelashes / Fill Ins Singles . . . . $25.00 & Up
( ) False Eyelashes / Eyelash Extensions.$300.00
( ) Eyelash Extensions / Fill Ins . . . . . . . . .$45.00 & Up
( ) False Eyelashes / Strips . . . . . . . . . . . . .$10.00
( ) False Eyelashes Removal Hard Glue . $25.00
This information will be kept confidential and will provide accommodations for future contacts.
Thank you very much for allowing me to perform my gifted services.
Please visit my eyebrowthreading site at www.eyebrowthreadingqueen.webs.com