Eyelash Extension Consent Form
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Format: (000) 000-0000.
Email
example@example.com
Health History | Please check any of the following that applies to you
Allergy to adhesives band aid or medical tape
Allergy to surgical glue or nail glue
Seasonal allergies
Allergy to glycerin
Eye illness or injury
Blepharitis (inflamed eyelids)
Permanent eye-makeup
Eye lift
Drugs that can cause temporary hair loss
Major surgery within last 120 days
Other
Are you currently pregnant?
Yes
No
If you are currently pregnant
I am aware that I am expected to lay on my back for a period of up to 2.5 hours
Not applicable
Have you ever had eyelashes extensions before?
Yes
No
If yes, have you had an allergic reaction to lash extensions?
Yes
No
Not applicable
Please agree to the terms and conditions
I hereby agree to have eyelash extensions applied to my natural lashes and consent to the placement and/or removal of the eyelash extensions by the certified professional.
I understand and agree to the after-care instructions and for any unexpected circumstance that have happened due to not following these instructions are in my own risk.
I understand that in rare occasions there are risks associated with having artificial eyelashes. I further understand that in rare circumstances eye or skin irritation and discomfort may occur.
I RELEASE MY TECHNICIAN LASH ARTIST FROM ALL LIABILITY ASSOCIATED WITH THIS PROCEDURE. THERE ARE NO GUARANTEES FOR THE BONDING TIME LENGTH OF THE EYELASH EXTENSIONS. LASH GYAL IS NOT RESPONSIBLE FOR ANY TECHNICIAN ERRORS. I UNDERSTAND THAT I HAVE BEEN ADVISED TO FOLLOW THE AFTERCARE PROTOCOL FROM MY TECHNICIAN SO AS TO AVOID ANY DISCOMFORT OR ADVERSE SIDE EFFECTS AFTER THE PROCEDURE HAS BEEN COMPLETED.
THIS AGREEMENT WILL REMAIN IN EFFECT FOR THIS PROCEDURE AND ALL FUTURE PROCEDURES CONDUCTED BY MY TECHNICIAN. I UNDERSTAND THAT THIS AGREEMENT IS BINDING AND THAT I HAVE READ AND FULLY UNDERSTAND ALL INFORMATION ABOVE.
I UNDERSTAND AND AGREE THAT IF I EXPERIENCE ANY OF THESE ISSUES WITH MY LASHES I WILL CONTACT MY TECHNICIAN AND HAVE THE EYELASH EXTENSIONS REMOVED IMMEDIATELY AND CONSULT A PHYSICIAN AT MY OWN EXPENSE.
I UNDERSTAND THAT AS PART OF THE PROCEDURE, EYE IRRITATION, PAIN, ITCHING DISCOMFORT AND IN RARE CASES EYE INFECTION MAY OCCUR.
I UNDERSTAND AND AGREE THAT IF I EXPERIENCE ANY OF THESE ISSUES WITH MY LASHES I WILL CONTACT MY TECHNICIAN AND HAVE THE EYELASH EXTENSIONS REMOVED IMMEDIATELY AND CONSULT A PHYSICIAN AT MY OWN EXPENSE.
I understand that because of the natural lash cycle and wear and tear, I will need to maintain my extensions with touch up appointments every 2 weeks to keep them full, and anything over 2 weeks is considered a new set.
I have read and understood the policies in place.
I understand there is a 10 minute grace period. Anything over 10 minutes will be considered a NO SHOW or I will pay $20 to keep my appointment. This will be determined by the lash artist.
Appointment
Client Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
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