Eyelash Extension Consent Form

Name

First NameLast Name

D.O.B

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Have you received eyelash extensions before?

Do you wear contacts?

Do you have or are you being treated for any eye illness or injury?

Are you able to lay on your back for 2+ hours to have your lashes applied?

Are you pregnant?

Are you allergic to adhesives (glues, tapes, plasters, gel pads etc.)?

Have you had eye Surgery in the past 4 months?

Disclaimer

I hereby certify that I have read all of the policies online and on the business social media associated with this form before my appointment.

I understand that this procedure requires single synthetic eyelashes to be glued to my own natural eyelashes. I understand that it is my responsibility to keep my eyes closed and be still during the entire procedure, until my eyelash technician addresses me to open my eyes. I understand that some risks of this procedure may be but are not limited to eye redness, swelling of eyelids and irritation. The fumes from the adhesive may cause my eyes to water if I open my eyes. I agree to disclose any allergies that I may have to latex, surgical tapes, cyanoacrylate, Vaseline, etc.

PUBLICITY MATERIALS I authorize the taking of clinical photographs and videos. I understand that photographs and video may be taken of me for educational and marketing purposes. I hold the practitioner harmless for any liability resulting from this production. I waive my rights to any royalties, fees and to inspect the finished production as well as advertising materials in conjunction with these photographs. I certify that if I do not wish to have my photos published or taken I may request not to do so at my appointment.

There are no refunds.

I certify that I have read the above consent and I fully understand it. I have been given ample opportunity for discussion and all my questions have been answered to my satisfaction. I hereby consent to this procedure. This constitutes the full disclosure and supersedes any previous verbal or written disclosures.

Signature