Eyelash Extension Client Consent Form

Name

First NameLast Name

Pronouns

ex. she/her

Phone Number

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

Email

example@example.com

Date

Referred by

First NameLast Name

Have you received an eyelash extension service before?

YesNo

If so, have ever had your eyelash extensions removed? Please explain.

Do you pick or pull at your eyelashes?

YesNo

Do you wear makeup often?

YesNoOnly special occasion

Have you received a permanent cosmetics service before? Ex. Microblading, Lip blushing, permanent eyeliner.

YesNo

Do you receive spray tan services?

YesNo

What position do you normally sleep in?

BackStomachSideAll of the above

Please list any and all allergies.

Have you used Retina A, Accutane or any medically prescribed skincare.

YesNo

Are you currently pregnant?

YesNo

Please list any and all vitamins or supplements.

Do you wear eye contacts?

YesNo

initial I understand that this procedure requires single and/or multiple fanned synthetic eyelashes to be adhered to my own natural eyelashes.

initial I understand that it is my responsibility to keep my eyes closed and to be still during entire procedure, until my eyelash artist addresses me to open my eyes.

initial I understand that some risks of this procedure may be, but not limited to eye redness and irritation due to fumes from the adhesive.

initial I agree to disclose any allergies or other topics talked about in the client consent form my eyelash artist should be aware of.

initial I agree that by reading and signing this consent form, I release Cherry Bxmb Beauty and Salon H3 from any claims of damages of any nature.

initial I give Cherry Bxmb Beauty and Salon H3 permission to show my before and after pictures to potential clients.

blanks I give Cherry Bxmb Beauty and Salon H3 permission to post my before and after pictures to social media.

blanks I confirm and agree that I wish to engage the services of Cherry Bxmb Beauty and Salon H3 to apply eyelash extensions.

initial Cancellation policy is fully understood.

blank I agree that I read, completed, and fully understood this entire consent form in it’s entirety and I have answered everything to the best of my ability. I have been informed of potentially harmful or negative side effects that could be caused by the application and/or removal process.