Eyelash Extension Consent Form

Name

First NameLast Name

Email

example@example.com

Phone Number

Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please agree to the terms and conditions

I understand that on rare occasions there are risks associated with having artificial eyelashes and eyelash extensions applied to or removed from my natural eyelashes. I further understand that in rare cases as part of the procedure eye irritation, discomfort and/or allergic reaction can occur. I agree if I experience any of these conditions with my lashes that I will contact the certified eyelash extension technician that performed this procedure and it may be beneficial to have the eyelashes removed at no additional cost, however The Beauty Room LLC will not offer a refund.I agree to the following eyelash extension follow-up and maintenance instructions (No waterproof mascara, No oil based products around the eyes, No tinting or perming of the eyelash extensions, No pulling or rubbing of the eyelash extensions, No water can come in contact with the eye area for 12 hours after the application, Should any kind of eye drops be necessary, extra care should be taken to prevent moisture from coming into contact with the eyelash extensions)

Health History | Please check any of the following that applies to you:

This agreement will remain in effect for this procedure and all future follow-ups conducted by the certified eyelash extension technician. I read English and understand that this consent agreement is legal and binding. I have read and fully understand all the information in this agreement. I am 18 years of age/or older and consent to the agreement and to the eyelash extension application procedure.

Client Signature

Date

Parent/Legal Guardian Name (If under 18 years old)

First NameLast Name

Parent/Legal Guardian Name Signature (If under 18 years old)

Date