Eyelash Extension Intake/Consent Form
Thank you for choosing Enlashment LLC. Please fill out this form before your appointment.
Client Information
(For ALL first-time clients)
Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
How did you hear about us?
*
Social Media (ex. Instagram, Tik Tok)
Google/web search
Family/Friend
Website
Other
Medical and Eyelash History
Have you had eyelash extensions before?
*
Yes
No
If yes, when?
-
Month
-
Day
Year
Date
Do you wear contacts?
*
Yes
No
Any allergies to cyanoacrylates, dyes, or perm solutions?
*
Yes
No
Have you ever had an allergic reaction to lash extensions or lash lifts?
*
Yes
No
Are you having lash extensions applied for a special occasion or daily wear?
*
Special Occasion
Daily Wear
Do you habitually rub, pull, or pick your lashes?
*
Yes
No
Do you have, or are you being treated for, any eye illness or injury?
*
Yes
No
Do you have any eye conditions? (Styles, infections, blepharitis, dry eyes, etc.)
*
Yes
No
What side do you predominately sleep on?
*
Right
Left
Neither
Are you able to keep your eyes closed and lie still for 2 to 3 hours?
*
Yes
No
Health History | Please check any of the following that applies to you
*
Permanent eye make-up
Use of retinoid for skin treatment
Blepharoplasty within last 6 months
Chemotherapy within last 6 months
Lasik Eye Surgery within last 120 days
Severe stress
Allergies to glycerin
Hormonal imbalance
Allergies to adhesive or synthetics
Recent high fever or severe illness
Alopecia
Iron deficiency
Oily skin or hair
Thyroid disease
Microdermabrasion
None of the above
Studio Policies (Client Agreement)
By signing below, you acknowledge and agree to the following:
*
Cancellation/Rescheduling Policy: Cancellations/reschedules within 48 hours will incur a 50% fee of the service total.
No-Show Policy: No-shows will be charged 50% of the service total.
Late Arrival: Arriving 10+ minutes late, may shorten the service or require rescheduling (at NO extra cost).
Non-Refundable Policy: Services are non-refundable, but I offer a 3-day touch-up for concerns or unsatisfactory.
*
Forms of Payment: We accept cash or Zelle (please bring exact cash). Any major credit cards/Apple pay, there will be a Virginia 6% tax included in your final sale.
Fills: We require all returning clients to schedule the appropriate fill appointment.
Foreign/Outside Fills: We do not offer foreign fills. If you are coming from another salon, a removal appointment must be made.
No Outside Products: We do not allow clients to bring in their own products.
Pre-care (Before Arriving)
*
Must arrive with clean lashes free of makeup, lash strip/falsies, clusters, mascara. A complimentary cleaning is provided before every service.
No contact lenses. Please remove contact lenses before the service.
No Fresh Lash lifts: Clients must wait 6-8 weeks after a lash lift before getting extensions.
Aftercare
*
Avoid rubbing, pulling, or sleeping directly on your face.
Wash your lashes daily. Use a lash cleanser and a soft brush. (Please do NOT use the mascara wands/spoolies to clean your lashes).
Brush lashes daily or when needed.
No mascara.
No mechanical curlers.
Cleanse lashes after the gym, pool/ocean contact.
Pat the area dry (DON’T wipe).
Best to sleep on your back if possible. Not required.
CONSENT FOR EYELASH PROCEDURE I have agreed to have eyelash extensions applied to and/or removed from my natural eyelashes. Before my licensed eyelash professional can perform this procedure, I understand I must complete this agreement and provide my informed consent by signing and dating where indicated below.
*
1. Waiver of Liability: I understand there are risks associated with having artificial eyelash extensions applied to and/or removed from my natural eyelashes, and that notwithstanding the utmost of care in the application or removal of these products, there still exists risks associated with the procedure and product itself, which include, without limitation, eye irritation, eye pain, discomfort, and, in rare cases blindness when improperly handled. As part of this procedure, I understand that a certain amount of eyelash adhesive material will be used to attach artificial eyelashes to my natural eyelashes. Even though the eyelash extension professional may apply or remove the artificial eyelashes properly, I understand adhesive material may become dislodged during or after the procedure, which may irritate my eyes or require follow-up care, at my own expense to prevent damage to my eyes. I also agree to defend, indemnify and hold harmless my service provider from any and all claims, actions, expenses, damages and liabilities, including reasonable attorneys’ fees which might be asserted against them as a result of my having this procedure performed.
2. Permission to Use Pictures (Optional): I hereby grant my service provider the full right to take, publish and reproduce photographs of me, my face, my eyes and/or eyelashes, both before and after the procedure, for any advertising, education, or other purposes whatsoever, including the right to retouch these photographs as deemed necessary. I further expressly assign any copyright in these photographs. I also grant consent to use my images and likeness as contained in these photographs, along with any comments I may provide.
3. Care and Maintenance: I agree to follow the care and maintenance instructions provided to me for the use and care of my eyelash extensions, and that if any follow up care is required due to my own mistake or negligence, or failure to follow these instructions, this will be at my own expense and risk. I understand that if I do any of the following, it may result in damage to my eyelash extensions or my cause my lashes to fall off prematurely. Knowing this I agree to follow these instructions for best results: I will avoid oil based eye products as these will loosen the bond of my eyelash extensions. I will avoid getting my lashes wet within 24 hours after application. For the first two days after application, I understand it is best to avoid swimming, saunas or steam rooms. If I experience any itching or irritation, I agree to contact my service provider immediately to have the lash extensions removed. I agree to avoid using waterproof mascara and to not use an eyelash curler, perm, or tint on my eyelash extensions. I agree not to pick, pull or rub my eyelash extensions. I understand that I should not attempt to remove my eyelash extensions on my own or with any product, but that the procedure requires that my eyelash extensions be professionally removed.
4. No Know Medical Conditions / Informed Consent: I have read and completed the Client Intake Form in its entirety and in truth. I acknowledge that I have been advised of the potentially harmful or negative side effects that the eyelash extension procedure or removal may cause to those who have specific medical or skin conditions. I understand that the adhesives and adhesive remover are a skin, eye and mucus membrane irritant and that in rare cases persons may be allergic or have hypersensitivity to synthetics, cyanoacrylate or formaldehyde which in small amounts may be present in the adhesive. I understand that the procedure requires that I lay still for up to 3 hours or longer with my eyes closed, and that if I wear contacts, I must remove my contact lenses for the duration of the lash extension application or removal. I further state that I have no known medical condition that might be aggravated by the procedure or any medical condition that would prevent me from complying with or heeding to instructions or these warnings.
If any action is brought to enforce the terms of this Agreement, the prevailing party shall be entitled to its costs and reasonable attorneys’ fees. Any claims arising out of this agreement will be resolved through the binding arbitration using the rules of the American Arbitration Association.
This Agreement will remain in effect for this procedure, and all future procedures.
I agree that this Agreement is binding upon me, and my heirs, legal representatives and assigns. I represent that I am at least 18 years of age and that I have the right to enter this agreement, or if I am under 18 years of age, I have my parent or legal guardians consent to this agreement and his or her relationship to me is as follows:_______________________. By his or her signature below, he or she ratifies and consents to this procedure under these terms.
Please hit ‘Submit’ at the bottom of this form once you have finished signing. You may then proceed to book your appointment. Thank you so much and I hope to see you soon! ⋆𐙚₊˚⊹♡
Name
*
First Name
Last Name
Client Signature (Please provide a clear signature)
*
Date
*
-
Month
-
Day
Year
Date
Under 18 Years of Age: Parent Name
First Name
Last Name
Parent Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: