Eyelash Extensions

Eyelash Extensions

Consultation & Consent Form
Name

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Email
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Contact Preference
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Client Health History
Are you allergic to acrylate/cyanocarylate (bonding agent)?
Have you ever had a reaction to adhesive tape or topical products?
Do you have an eye disease, condition, or injury that has affected your hair/lash growth or loss?
Please list any other allergies you may have (including cosmetics): Enter Here
Do you currently have, or ever had, any of these conditions?
Any other health conditions not listed: Enter Here
Please list all current medications you are taking (including over-the-counter herbs, vitamins and supplements): Enter Here
Have you ever had eyelash extensions or removal of eyelash extensions?
If yes, please list any bad reactions you experienced: Enter Here
Do you wear contacts or glasses?
Have you had any recent injections or tattoos done around your eye area?
Is there anything else we should know? Enter Here
Pre & Post Treatment Care Guide
Your lash extensions are attached to your own individual eyelashes and will fall out when your natural lashes shed. Maintaining your lash sets will require regular visits to remove grow out and attach new extensions (refills) as your eyelash growth cycle regenerates new lashes. With a few simple care instructions you will be on your way to enjoying your luscious long lashes. To increase the longevity of your lashes, it is advised to avoid touching as much as possible.

Before your appointment:
- Avoid using mascara 2-3 days before your appointment. The stubborn film it leaves on your lashes may prevent the extensions from adhering correctly.
- Arrive to your appointment with CLEAN lashes and makeup-free eyes.
- Remove contact lenses before your appointment as it may react to the adhesive.
- Do not drink caffine as it causes eye twitching and restlessness. This may result in fumes getting into your eyes due to them not staying closed properly.
During the initial 24 hours after your appointment: Do not get your lashes wet for after the lash extensions are applied. It will affect the efficacy of the glue.
- Avoid steam from showers, facials, saunas and swimming pools.
- Avoid getting moisture around the eye area when washing face, showering, etc.
- Avoid doing activities that make you sweat (this includes tanning).
General guidelines to extend the life of your lashes
- Avoid using oil-based products, including mascara and makeup remover.
- Avoid rubbing your eyes or lashes, especially when washing your face. It is recommended to clean around the eye area with a washcloth or cotton swab.
- Do not use an eyelash curler. One of the benefits of lash extensions is the ability to add curl to your lashes. If you would like more curl, please contact your technician.
- If you can, sleep on your back to avoid the risk of lashes getting smashed against your pillow.
- Regularly clean your lashes with a foam cleanser made specifically for lash extensions.
- Gently brush your lashes with a clean mascara wand to groom them.
- Do not pick/pull your lashes, nor attempt to remove them yourself. If you experience and pain, redness or irritation; contact your technican immediately. A free removal/ touch up service will be offered within 3 days of your appointment.
Informed Consent

Please Initial:
I understand the services may take over 2 hours. I agree to keep my eyes closed and lay as still as possible during the whole procedure to prevent the movement of my eyelids. I understand that failing to do so may result in my technician having difficulty applying the extensions, accidental pricking from tweezers, and/or fumes from the adhesive causing irritation and eye redness.
Initial
I understand that the lash extension services have some inherent risk of irritation to the orbital eye areas, including the eye itself, and could result in stinging, burning, blurry vision, or (in rare case) potential blindness should the adhesive enter the eye or should an allergic reaction occur.
Initial
I understand that this is a semi-permanent procedure; as my natural lashes will continue to grow and fall out normally, making “refill” appointments every 2-3 weeks are necessary to maintain the original look achieved by replacing the lashes that have fallen out.
Initial
I understand that while every attempt will be made to provide me with the length and fullness I have chosen, my final result may not be what I initially envisioned due to uniqueness in eye shape.
Initial
I understand that it is imperative that I complete the client health history section of this form and have cited all conditions regarding my health history, medications being taken, and any past reactions to products or medications.
Initial
I understand that additional conditions could occur to be discovered during the procedure which could affect my ability to tolerate the procedure.
Initial
I understand HI tax of 4.712% will be included in the total cost of the service and that there’s an additional 3% processing fee for card/contactless payment. If paying with cash, I may not be able to receive change.
Initial
I understand the cancellation policy to which I must notify my esthetician if I need to cancel or reschedule my appointment no less than 24 hours before my appointment time. I understand that if I fail to do so, don’t show up to my appointment, or arrive more than 10 minutes late, I am in violation of the cancellation policy and I agree to pay the fee of 50% of the service.
Initial
I content to “before and after” photographs and videos for the purpose of documentation, potential advertising, and promotional purposes.
Initial (optional)
Acknowledgement & Waiver

I am over 18 years of age and consent to the agreement and treatment, or have a parent with me that consents to this service.
This agreement will remain in effect for this procedure and all future procedures conducted by my lash extension technician, Jessica Mae Tagalicud. I understand that this consent agreement is legal and binding. I have read and fully understand all information in this agreement. I understand my lash technician will take every precaution to minimize or eliminate negative reactions as much as possible. I release my lash technician from all liability associated with this procedure, which is performed with the utmost attention to safety and proper application. In the event I may have additional questions or concerns regarding my treatment, I will consult my lash technician immediately. I have accurately answered the questions above and included any known allergies, prescription drugs or products I am currently ingesting or using topically. I certify that I understand and accept the potential risks and that I have had sufficient opportunity for discussion to have any questions answered. I do not hold my lash technician 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. By signing below, I verify that I have read, understand, and agree to the above statements.
Date

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Signature
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Eyelash Extensions

Client Health History

Pre & Post Treatment Care Guide

Informed Consent

Acknowledgement & Waiver