Lash extensions

  • Sisters Beauty Room LLC

    Eyelash Extension Consultation & Consent Form
  • Date of Consultation*
     - -
  • Format: (000) 000-0000.
  • Is this your first time getting lash extensions?*
  • Have you ever had lash extensions removed?*
  • Have you used any kind of under eye gel patches before?*
  • Do you wear glasses?*
  • Do you wear contacts?*

  • If you do wear contacts on a regular basis, please do not wear them to your appointment. 

  • Do you pull on your lashes or rub your eyes often?*
  • How do you sleep?(choose all that apply)*
  • Do you go tanning or get spray tans?*
  • Have you had an permanent makeup applied to or around your eyes?*
  • Are you pregnant?*

  • Please be advised that if you are pregnant, you will be laying on your back for a long period of time. I will do my best to accommodate you and allow you to lay on your side as needed. You are more than welcome to bring any additional pregnancy pillows to help with comfort.

  • Do you exercise?*
  • Do you wear makeup?*
  • Are you on any special diet?*

  • Do you have any allergies or sensitivities to any of the following:

  • Acrylates or cyanoacrylate? (Topical adhesives)*
  • Nail adhesives?*
  • Tape/bandages?*
  • Makeup, skincare products, or specific ingredients in skincare products?*
  • Have you had any eye surgery, wounds or infections in the last 4 weeks?*
  • Have you had any type of exfoliating, skin-tightening or skin resurfacing treatments in the last 4 weeks? (For example: Chemical peels, microdermabrasion, laser, acne treatments)*
  • Do you have any history of eye disease, condition or injury that has affected the growth/loss of your natural lashes?*
  • Are you currently on any medication?*
  • Do you have any of the following conditions: (please select all that apply)*

  • Waiver of Liability

    I understand there are risks associated with having artificial eyelashes applied to and/or removed from my existing eyelashes, and that not withstanding the utmost of care in the application or removal of these products, there still exist risks associated with the procedure and product itself, which include, without limitation, eye irritation, eye pain, discomfort, and, in rare cases, blindness even when applied in the usual manner. If I experience any irritation, redness, puffiness, itchiness, an allergic reaction or any other side effect of this procedure, I will contact a medical doctor immediately. As part of this procedure, I understand that a certain amount of eyelash adhesive material will be used to attach the artificial eyelashes to my existing eyelashes. Even though the eyelash extension artist may apply or remove my eyelash extensions in the usual manner, I understand adhesive material may become dislodged during or after the procedure, which may irritate my eyes or require further follow-up care, at my own expense to prevent damage to my eyes. I also understand there is more than one technique for applying eyelash extensions to my eyelashes, and I will not attribute any liability to the eyelash extension artist as a result of this procedure or the use and care of these lashes. As part of the removal procedure, I understand that a certain amount of chemical adhesive remover is applied to existing adhesives and a reaction occurs to dissolve the adhesive that results in the thinning of the remover. Even though the eyelash extension artist may apply or remove my eyelash extensions in the usual manner, I understand the liquid remover may seep into my eyes, which may irritate my eyes or require further follow-up care, at my own expense to prevent damage  to my eyes. I also agree to defend, indemnify and hold harmless the eyelash extension artist 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.

     
    No Known Medical Conditions / Informed Consent

    I have read and completed the Eyelash Extension Intake Form in its entirety and in truth. I acknowledge that I have been advised of the potential harmful or negative side effects (such as the premature shedding of my eyelash) that the lash extension procedure or removal may cause to those who have specific medical or skin conditions. I understand that the adhesives and adhesive remover are a skin, eye and mucus membrane irritant and that in rare cases persons may be allergic or have hypersensitivity to synthetics, cyanoacrylate or formaldehyde, which in small amount may be present in the adhesive. I understand that the procedure requires that I lay still for up to 2 hours or longer with my eyes shut, and that if I wear contacts, I must remove my contact lenses for the duration of the lash extension application or removal. I further state that I have no known medical condition that might be aggravated by the procedure or any medical condition that would prevent me from complying with or heeding to the eyelash extension artist's instructions or these warnings.

     

    Care and Maintenance

    I agree to follow the care and maintenance instructions provided by the eyelash extension artist for the use and care of my eyelash extensions, and that if any follow up care is required due to my own mistake or negligence, or failure to follow these instructions, this will be at my own expense and risk. I understand that if I do any of the following, it may result in damage to my eyelash extensions or may cause my lashes to fall off prematurely. Knowing this I agree to follow these tips for best results: I will avoid oil based eye products, as these will loosen the bond of my eyelash extensions.
 If I experience any itching or irritation, I agree to contact a medical doctor immediately and the eyelash extension artist to have the eyelash extensions removed.
 I agree to avoid using waterproof mascara and to not use an eyelash curler, perm, or tint my eyelash extensions.
 I agree to not pick, pull or rub my eyelash extensions. I understand that I should not attempt to remove my lash extensions on my own or with any product, but that the procedure requires that my eyelash extensions be professionally removed. I understand that if I pick, pull on, or rub my eyelash extensions it may result in the premature temporary and permanent loss of my artificial and natural eyelashes. 

  • Permission to Use Photos

    I,   *  , herby grant my lash extension artist the full right to publish pictures of my face, my eyes and/or eyelashes, both before and after this procedure, for any advertising or education, including the right to retouch these pictures as deemed necessary by the eyelash extension artist. I further expressly assign any copyright in these pictures to the eyelash extension artist. I also grant my consent for the eyelash extension artist to use my image and likeness as contained in these pictures for any advertising or other purposes.

  • Date*
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