3141 E Broad St Suite 303 Room 114, Mansfield, TX 76063
(682) 213-0798
lealux.glossgenius.com
Eyelash Extension Consent Form
Client Details
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
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Medical Information
Do you have any of the following conditions? They may determine that you are not suitable for eyelash extensions.
Allergy to adhesives such as glues and tapes. (Explanation: Eyelash extension uses tape, glues and gel pads that may cause a reaction.)
*
Yes
No
Chemotherapy or radiation treatments within the last 6 months. (Explanation: The medication for chemotherapy may cause a reaction to the materials used for eyelash extensions.)
*
Yes
No
Thyroid medication. (Explanation: Eyelash extensions will not last due to the medication in the system.)
*
Yes
No
Lasik surgery, glaucoma or blepharoplasty within the last 6 months. (Explanation: Eyes may have sensitivity to eyelash extensions and products used for prepping the eye area such as glue and gel pads.)
*
Yes
No
Use of eyelash growth serums or conditioners within last 4 weeks. (Explanation: These products can contain ingredients such as glycerin and oil that may interfere and affect the glue and its bonding power. It is suggested to discontinue use of any growth product prior to application of eyelash extensions.)
*
Yes
No
Contact lenses. (Explanation: Glue used to apply the eyelash extensions may get underneath the contact lens and can cause abrasion or scratching. Contacts must be removed prior to eyelash extension application.)
*
Yes
No
Extremely oily skin and hair. (Explanation: Natural oils can break down the adhesives used to bond the eyelash extensions causing them to fall out.)
*
Yes
No
Seasonal allergies. (Explanation: These allergies may cause swelling, itching and redness during the time the pollen count is the highest.)
*
Yes
No
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Consent
Please check each box to show your understanding and agreement.
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Signature
This agreement will remain in effect for this procedure and all future eyelash extension procedures. I will alert the technician if there are any future changes to my medical history. I have read and fully understand all information in this agreement. I am over 18 years of age and consent to the agreement and to the eyelash extension procedure.
Signature
*
A copy of this signed agreement will be emailed to you.
Submit
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