Eyelash Extension Consent Form
Thank you for choosing Elevated Esthetics. We are looking forward to a long and lengthy communication.
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about us?
Facebook
Instagram
Web search
Referral
Other
Other
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
Seasonal allergies
Allergy to glycerin
Eye illness or injury
Blepharitis (inflamed eyelids)
Permanent eye-makeup
Eye lift
Drugs that can cause temporary hair loss
Major surgery within last 120 days
Other
Have you ever had eyelashes extensions before?
Yes
No
If no, we 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)
Yes
No
If yes, where have you had them applied and what brand was used?
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 and discomfort 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.
Date
-
Month
-
Day
Year
Date
Client Signature
Technician Name
First Name
Last Name
Technician Signature
Submit
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