Eyelash Extension Consent Form
Thank you for choosing Buffalo Beauty Lounge! We are Borboleta certified!
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Date of birth
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about us?
*
Website
Magazine
Web search
Friend
Other
Health History | Please check any of the following that applies to you
*
Pregnant
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
Alopecia
None of the above
Other
Have you ever had eyelashes extensions before?
*
Yes
No
If yes, did you have any allergic reactions to the eyelash extensions?
*
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 1 to 3 weeks to keep them full.
Date
*
-
Month
-
Day
Year
Date
Client Signature
*
Technician Name
First Name
Last Name
Technician Signature
Email
example@example.com
Submit
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