Lash Extensions Client Form

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

DOB (Date of Birth)

Date

How did you hear about us? Who referred you?

*Please put the name of the person who referred you

Instagram Name

Are you allergic to Acrylate/Cyanoacrylate (bonding agent)?*

YesNoUnsure

Have you ever had a reaction to adhesive tape, or other topical products?*

YesNo

To help us design your ideal lash look, please upload a clear, well-lit photo of your eyes and face. This allows us to assess your natural lashes, eye shape, and features so we can customize your lash extension application with precision. Your photo will be kept strictly confidential and used only for this purpose.

Photo Example

Upload Photo Here*

Risks & Procedure Awareness
I understand and acknowledge:

Lash extension services carry some inherent risk of irritation to the eye area, including the eye itself, which may result in stinging, burning, or blurry vision if adhesive enters the eye or triggers an allergic reaction.
Some irritation, itching, or burning may occur on the skin if bonding agent comes into contact with it.
Additional conditions may arise or be discovered during the procedure that could affect my tolerance.

Initial*

Semi-Permanent Nature & Maintenance
I understand:

This is a semi-permanent procedure; my natural lashes will continue to grow and shed.
Fill appointments every 3-4 weeks are necessary to maintain the look achieved.

Initial*

Patch Tests
I understand:

I may arrange, at my discretion, a spot test 24–48 hours before my full set to check for potential reactions.
Arranging a spot test is my responsibility and does not affect this agreement or any clauses contained herein.

Initial*

Health & Safety
I confirm that I will communicate any known:

Allergies
Eye infections or recent surgeries
Skin sensitivities or medical conditions

I understand that failure to disclose any conditions may increase my risk of reaction or damage.

Initial*

Photo & Media Consent
I consent to before-and-after photos for documentation, marketing, or promotional purposes.

Initial*

Release of Liability & Indemnity
I give permission for my technician to perform the lash extension procedure discussed. I understand:

The lash extension specialist will take all reasonable precautions to minimize risks, but cannot guarantee results.
I release Glamour Brows, the lash extension artist, and all staff from any claims, actions, expenses, damages, or liabilities — including reasonable attorney fees — arising from this procedure or any products purchased.
I agree to defend, indemnify, and hold harmless Glamour Brows and its staff from claims related to my procedure.

Initial*

Client Acknowledgement
I certify that:

I have read, fully understand, and had the opportunity to discuss this consent form.
I accept the risks and nature of the procedure.
I voluntarily consent to receive lash extension services.

I understand that lash extension services have some inherent risk of irritation to the orbital eye area, including the eye itself, and could result in stinging and burning, blurry should the adhesive enter the eye or should an allergic reaction occur. I understand that some irritation, itching or burning may occur on the skin if the bonding agent comes into contact with it.
Initial*

I understand that this is a semi-permanent procedure, as my natural lashes will continue to grow and fall out normally, making touch up or “fill” appointments necessary to maintain the original look achieved by replacing the lashes that have fallen out. Most clients require a fill appointment every 2-3 weeks.
Initial*

I understand, that should I have any concerns about any possible reaction to chemicals and products used, I may arrange at my own discretion to book an advance spot test where 2 to 3 individual lashes will be applied 24-48 hours prior to the time in which I’m scheduled for my initial full set. I further agree, that this shall be my own responsibility and at my sole discretion and have absolutely no bearing on the contents or signing of this agreement or any clauses contained therein.
Initial*

I understand that additional conditions could occur or be discovered during the procedure which could affect my ability to tolerate the procedure.
Initial*

I consent to “before and after” pictures for the purpose of documentation, potential advertising and promotional purposes.
Initial*

I understand that if I have any concerns, I will address these with my technician. I give permission to my technician to perform the lash extension procedure we have discussed, and I also agree to defend, indemnify and hold harmless Glamour Brows, the eyelash extension artist & all it’s staff from any and all claims, actions, expenses, damages and liabilities, including reasonable attorneys’ fees which might be asserted against her as a result of my having this procedure performed, or my purchase of these eyelash extension products from her.. I understand my lash extension specialist will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult the lash extension specialist immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures.

I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the lash extension specialist, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today.

Signature*

Date*

Date