Eye Lash Extensions Intake & Consent Form
Full Name
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First name
Last name
Cell Phone Number
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Email
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example@example.com
I release LeLushes Beauty from any and all liability associated with this procedure. This service will be performed with the utmost attention to safety, sanitation, and proper application using tools and products that the technician has been trained and certified to use. This service has many variables due to lifestyle, moisture, weather, extreme temperatures, natural eyelash shedding and other factors. The technician (along with my consent form and consultation) will decide if I am a good candidate for this service to the best of their ability.
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Initial
I grant permission to LeLushes Beauty to use my before and after photos for marketing or examples of my technicians work. *We will make you look GLAM!*
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Yes
No
I acknowledge and understand that the studio doesn’t offer refunds. LeLushes Beauty will do their ultimate BEST to provide a service experience to meet your satisfaction and expectations to LOVE your lashes every appointment.
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Initial
I acknowledge LeLushes Beauty does their full effort to fulfill my appointments times and I respectfully acknowledge the times I schedule to be available. I understand the following set CANCELLATION policies that are also non-refundable agreements of service. -If you cancel or reschedule 48 hrs before your appointment, a 50% of the service fee will be accessed upon cancellation. Second cancellation offense, you will be charged the full appointment amount. If you cancel often you will be no longer able to book with LeLushes Beauty. While things may happen, we advise appropriately booking.
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Eyelash extensions require on-going maintenance (similar to a nail service). Refills are recommended approximately every 2 to 3 weeks. I understand if I go beyond this recommended time it may result to an incur (higher) service cost as a full-set.
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Initial
Is this your first time having Eye-lash Extensions?
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Yes (I'm EXCITED!)
No (I'm a Diva, I need them 4 EVER!)
Do you wear Contacts?
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Yes
No
Are you having lash extensions applied for?
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Special occasion (Places to go.. People to see!)
Daily wear (It's a LOOK necessity)
Do you often rub, pull or pick your lashes for any reason?
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Yes
No
How do you usually sleep? Please note, you will lose more eyelash extensions on the side on which you sleep. Sleeping on your stomach will affect them the most. It is important to refrain from sleeping on your stomach for the first 2 days after your service to allow the adhesive to set properly.
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Side
Stomach
Back
Do you have a severe eye illness or are you being treated for an eye injury?
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Yes
No
Are you able to lay on your back for 2 - 3 hours to have your lashes applied?
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Yes
No
I understand and consent to having my eyes closed and covered for the duration of approximately 60-180 minute procedure. Times may vary depending on the type and number of eyelashes applied.
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Please initial you read and understand the above.
Are you pregnant?
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Yes
No
It is also recommended to avoid all oil-based products around your eyes for as long as you wear your lashes. Oil based products, waterproof mascaras and liners will loosen the adhesive and your lashes will not last long.
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Please initial you read and understand the above.
Do you use lash growers such as Lattice or lash serums? It is best to discontinue use of these type of products 2 weeks before your service and discontinue used while you are wearing your lash extensions. Some contain oils/steroids and will shorten the duration of your extensions. There is eye-lash extensions approved products for your natural lashes that we can recommend while you have extensions.
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Yes
No
I understand and agree to the after-care instructions provided by the certified eyelash extension professional for the use and care of my eyelash extensions. I realize and accept the consequences of failure to adhere to these instructions may cause the eyelash extensions to fall out and/or decrease the time the lashes will last.
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Please initial you read and understand the above.
The following conditions are not suitable for eyelash extensions. Possible adverse reactions are listed below each condition
Are you allergic to adhesives (glues, tapes, band aids, etc)? This service may use adhesives tapes, glues and gel pads that may cause an allergic reaction. We use a medical grade, formaldehyde free glue, but allergies may still occur?
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Yes
No
Have you had Chemotherapy treatments in the last 6 months? Medication for chemotherapy may cause a reaction to the materials used in this service. Also, if lashes are just starting to grow back they may be a little weak and we recommend waiting until they are strong enough for this service.
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Yes
No
Have you had Lasik Surgery in the past 4 months? Eyes may have sensitivity to eyelash extensions and products used for prepping the eye area. (gel pads, glues, etc.)
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Yes
No
Are you currently taking Thyroid Medications? Thyroid medications or Thyroid conditions may not have lash extensions last long due to either of these
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Yes
No
Blepharoplasty or other eye condition or surgery in the last 6 months? Blepharoplasty, eye surgery or conditions may have sensitivity to eye-lash extensions and products used. Consult your doctor first and ask if it's safe for you to have this service
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Yes
No
I agree to have eyelash extensions applied to my natural eyelashes and/or removed and retouched. By signing this agreement, I consent to the placement and/or removal of the eyelash extensionsby the certified eyelash extension professional.
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Initial
I understand that in 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 and discomfort could occur. I agree that if I experience any of these conditions with my lashes that I will contact the certified eyelash extension professional that performed this procedure and it may be beneficial to have the eyelashes
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Initial
I agree and understand that LeLushes Beauty & my Lash Technician have no way of knowing if the client is allergic to some of the products or materials being used in any eye-lash procedure, though we do use sensitive eye products to ensure comfort every client is different. LeLushes Beauty does offer patch tests to those that are not sure if they are a good candidate and will help to discuss options. I will seek medical care (at my own expense) and contact my technician immediately if any allergic or adverse reaction occurs. All of my questions were answered and I understand the procedure and risks.
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Initial
I hereby acknowledge all risks associated with performing this procedure and have been informed of posible post-procedure side effects. Any concerns I have with this procedure have been addressed by my service provider. I understand that my service provider will take all necessary precautions to prevent risks from occurring during the procedure & release them from all liability when assuming these risks. I will adhere to all post-procedure recommendations made by my service provider to ensure best quality of service. I certify that all above information is correct and that I have disclosed all conditions that may affect my quality of service and risks associated with my service provider. I have not withheld any information that may increase risks associated with agreed services
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Initial
This agreement will remain in effect for this procedure and all future follow-ups conducted by the certified eyelash extension professional. I read English and understand that this consent agreement is legal and binding. I have read and fully understand all information in this agreement. I am over 18 years or age and consent to the agreement and to the.
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Initial
Sign date
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Month
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Day
Year
Date
Thank you giving us the time to get to know YOU & signing the Consent form, its much appreciated towards your lash experience!
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By signing below, I verify that I have read and understand the above statements and agree to have answered medical questions honestly to my knowledge.
Client signature
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I'm Ready Girl! XOXO
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