Eyelash Extension Consent Form
Street Address Line 2
State / Province
Postal / Zip Code
How did you hear about us?
Health History | Please check any of the following that applies to you
Allergy to adhesives band aid or medical tape
Allergy to surgical glue or nail glue
Allergy to glycerin
Eye illness or injury
Blepharitis (inflamed eyelids)
Drugs that can cause temporary hair loss
Major surgery within last 120 days
Have you ever had eyelashes extensions before?
If no,would you like to have a patch test which we highly recommend? (Note that a patch test does not guarantee that an adverse reaction will never happen)
Please agree to the terms and conditions
I hereby agree to have eyelash extensions applied to my natural lashes and consent to the placement and/or removal of the eyelash extensions by the certified professional.
I understand and agree to the after-care instructions and for any unexpected circumstance that have happened due to not following these instructions are in my own risk.
I understand that in rare occasions there are risks associated with having artificial eyelashes. I further understand that in rare circumstances eye or skin irritation, discomfort or an allergic reaction may occur.
I understand that because of the natural lash cycle and wear and tear, I will need to maintain my extensions with touch up appointments usually recommended about every 2 to 3 weeks to keep them full.
I understand that no refunds are issued on any services, exchanges are made on defective items only
I give permission to Gabrielle Quintanilla, dba “Angel Lash Lounge” to show my before and after photos and/or videos to other potential clients as needed without claim (e.g. Facebook, Instagram, website, etc.)
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 Gabrielle Quintanilla from all liability, demands, or claims associated with this procedure
I understand that there is a 2 day cancellation policy. If I cancel my appointment within 2 days of the scheduled date, I will be charged 50% of the service price.
I understand that card information is required to book an appointment for possible cancellations and no show fees (50% of service).
Parent/ Guardian Signature (if client is under 18 yrs old)
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