Eyelash Consent Form

Name*

Phone Number

Emergency Contact Number

Your email*

How did you hear about us?*

Facebook

Instagram

Google Search

Friend

Other

Is this your first time having lash extensions applied?*

Yes

No

What are your lash goals? (Click all that apply)*

Longer

Fuller

Dramatic

Mascara-look

Natural

Do you wear contact lenses or glasses?*

Yes

No

Do you habitually rub, pull, or pick your lashes for any reason?*

Yes

No

Do you have, or are you being treated for any eye illness or injury?*

Yes

No

Are you able to keep your eyes closed, avoid talking and lie still for up to 2 hours or longer?

Yes

No

Please check off any of the following that might apply to you:*

Laser Eye Surgery

Dry Eye

Pink Eye (Conjunctivitis)

Seasonal Allergies

Allergies to adhesives or synthetics

Irritated or Broken Skin

Recent Chemical Peel

Hypersensitivity to cyanoacrylate or formaldehyde

Hormonal imbalance or extreme stress

Chemotherapeutic agents used in cancer treatment

Cataract Surgery

Diabetic Retinopathy

Medication causing temp. hair loss

Sty

Blepharoplasty

Eczema on lids

Psoriasis on lids

Accutane use

Permanent Makeup

Allergies to latex

Allergies to acrylic nails

Alopecia

Lash Loss

Blepharitis

Glaucoma

None listed

I understand that this procedure requires synthetic eyelashes to be adhered on to my own natural eyelashes using the very precise application of placing an extension (classic individual or volume fan) on a single natural eyelash.*

Yes I understand

It’s my responsibility to keep my eyes closed and be still during the entire procedure. Please do not bring company.*

Yes I understand

I acknowledge that I’ve been informed of potentially harmful or negative side effects that may be caused by the application or removal of eyelash extensions and hereby fully release, agree to hold harmless and forever discharge the lash technician from all liability, demands, or claims associated with this procedure. Risks of this procedure may result in, but not limited to, eye redness and irritation. Products used during this procedure may release fumes and can cause eyes to water. If any unusual symptoms, injury or allergy is suspected, all future appointments will cease until cleared by your physician *

Yes I understand

I agree to disclose all medical history and any changes when returning including skin conditions and/or any allergies that I may have to latex, surgical tapes, cyanoacrylate, etc.*

Yes I understand

If I need to cancel or reschedule any of my appointments, I will inform you ASAP. If I give less than a 24-hr. notice, I will agree to pay a late cancellation fee (50% of service) or if no call/no-show (100% of service). *

Yes I understand

Arriving late will reduce the time of service. If I am more than 15 minutes late, my appointment will be cancelled with a late fee. This is to ensure there is enough time to complete the service and out of consideration to the clients following after.*

Yes I understand

Fill prices depend on quantity remaining. Anything less than 50% of lashes per eye or after 3 weeks since last service, will require a full set charge.*

Yes I understand

I confirm that I have read and fully understand all agreements and conditions outlined and am signing voluntarily, agreeing to proceed with services. *

Yes I understand

By typing your full name below you agree to all terms and conditions stated above. *

Date*

EyeLash Consent Form

*Note: Your privacy is important to us. We will not sell or share your personal information with third parties, unless required by law

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