Lash Extension Consent Form
@lashedbydelilah
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Instagram
Referred by(optional)
Is this your first time getting lash extensions?
Yes or no
If No, have you ever experienced any reactions?
Do you have any allergies, please specify.
Do you wear contact lenses
Yes
No
Are you pregnant?
Yes
No
Do you have any eye conditions, or currently being treated for an eye injury
Yes
No
I understand that this is a semi permanent procedure, I consent to have synthetic lash hair glued to my own natural lashes. I agree to have extensions applied/removed or retouch.
I consent
I do not consent
I understand in order to have the eyelash extensions applied to my eyelashes I will need to keep my eyes closed for duration of 2-3 1/2 hours during the procedure. I also understand that I will need to be lying in a reclined position.
I consent
I do not consent
I understand that some risks of this procedure may be but not limited to irritation and redness. The fumes from adhesive may cause my eyes to water if I open my eyes.
I consent
I do not consent
I understand that there might be a risk of an allergic reaction to the lash extensions, I agree if I experience any reaction I will notify my lash technician and may be necessary to have extensions be removed. If i have any concerns I will address it with my lash technician.
I understand
I do not understand
I agree to notify technician if I suffer from any allergies like latex, surgical tapes, cyanoacrylate, vaseline, etc.
I agree
I do not agree
I agree that I am over 18 years of age, if below 18 years of age a parent or guardian must also sign this form.
I agree
I do not agree
Other
I understand that lash after care needs to be followed, if aftercare is not correctly followed this can result in fall out, and or infections through bad hygiene.
I understand
I do not understand
I understand that there are many variables to the overall life of my lash extensions, hair growth cycle, use of cosmetics, etc. My natural lashes will continue to grow and fall out naturally making a "fill " or touch up appointment necessary ever 2-3 weeks.
I understand
I do not understand
I understand that there are absolutely no refunds or exeptions, issues with my new lashes needs to be addressed within 48 hours of my appointment, after the 48 hours there will be a charge.
I understand
I do not understand
I consent to have before and after pictures taken for advertising/marketing purposes. I understand that these pictures will be posted on social media.
I consent
I do not consent
I agree that I have read and understood this consent form, and have answered everything to my best ability, I have been informed of all the negative side affects that may be caused by lash extensions. I release LashedbyDelilah from any claims or damages by any nature. I confirm to engage the services of Lashedbydelilah to apply lash extensions.
I agree and understand
I do not agree or understand
Date
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Month
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Day
Year
Date
Signature
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