Eyelash Extension Consent Form
Client
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Have you received eyelash extensions before?
Yes
No
Have you had eyelash extensions removed?
Yes
No
Have you used under eye gel patches or foam tape before?
Yes
No
Do you wear contacts? If so, please remove prior to your lash appointment.
Yes
No
Do you have or are you being treated for any eye illness or injury?
Yes
No
Are you pregnant?
Yes
No
Are you able to lay on your back for 2-3 hours to have your eyelash extensions applied?
Yes
No
Are you allergic to adhesives(glues, tapes, band aids, Cyanoacrylate, etc)or have any allergies that you know of at all?
Yes
No
Have you had Lasik eye surgery within the past 4 months?
Yes
No
Do you have extremely oily skin or hair?
Yes
No
By checking the following boxes, confirm that you willingly consent to the following terms and conditions:
I understand that this procedure requires single synthetic eyelashes to be glued to my own natural eyelashes. I understand that it is my responsibility to keep my eyes closed and be still during the entire procedure, until my eyelash technician addresses me to open my eyes. I understand that some risks of this procedure may be but are not limited to eye redness, swelling of eyelids, an allergic reaction and irritation. The fumes from the adhesive may cause my eyes to water if I open my eyes. I agree to disclose any allergies that I may have to latex, surgical tapes, cyanoacrylate, etc.
I understand that the Esthetician’s time, product and other expenses will be used to provide me with a service, therefore, agree that no refunds will be issued at any time for any reason. However, if I am unhappy with the service or experience any problems within 72hours after my appointment, I will be sure to let the artist know. Anything past the 72 hours will be subject to full price.
PUBLICITY MATERIALS I authorize the taking of photographs and videos. I understand that photographs and video may be taken of me to be used for educational and marketing purposes. I hold the practitioner harmless for any liability resulting from this production. I waive my rights to any royalties, fees and to inspect the finished production as well as advertising materials in conjunction with these photographs.
I certify that I have read the above consent and I fully understand it. I have been given ample opportunity for discussion and all my questions have been answered to my satisfaction. I hereby consent to this procedure. This constitutes the full disclosure and supersedes any previous verbal or written disclosures.
I understand that in rare occasions there are risks associated with having artificial eyelashes and eyelash extensions applied to or removed from my natural eyelashes. I further understand that in rare cases as part of the procedure eye irritation, allergic reaction and discomfort could occur. I agree that if I experience any of these conditions with my lashes that I will contact the certified eyelash extension professional that performed this procedure and it may be beneficial to have the eyelashes removed.
I understand and agree to the after-care instructions provided by the certified eyelash extension professional for the use and care of my eyelash extensions. I realize and accept the consequences of failure to adhere to these instructions may cause the eyelash extensions to fall out and/or decrease the time the lashes will last and will not hold the lash technician responsible for my inattentiveness.
I understand that because of the natural lash cycle and wear and tear, I will need to maintain my extensions with refill appointments usually recommended every 2 weeks and understand my technician also offers 1 week "mini fills" in the event that my lashes cannot be maintained for a full 2 weeks.
I agree to the following eyelash extension follow-up and maintenance instructions: - No waterproof mascara- No oil based products around the eye area- No water can come into contact with the eye area for 24 hours after application- No tinting or perming of the eyelash extensions- No excessive rubbing or any pulling of the eyelash extensions- When showering, do not let water hit you directly in the eyes- After cleansing lashes, be sure to pat dry or blow dry on cold and low setting before brushing- No sleeping on your lashes.
If you currently have eyelash extensions on from another lash artist, there may be the possibility that your current extensions will need to be removed and re-applied properly. Thus, if you are coming in for a fill from another lash artist, then you agree that your current extensions may need to be removed ( at an extra charge) and a new full set will be applied at the appropriate full set price. This will be discussed and fully explained to you prior to any service being performed.
You are paying for artist time, product and other expenses used to provide you with a service. No refunds will be given for any reason. If any issues arise, you have 72 hours after your appointment to discuss your concerns and if a fix can be done to address your concerns, it will be done so with a complimentary touch up if it is at the fault of application or product. Any concerns addressed after 72 hours of your last appointment, or if you failed to follow the proper aftercare instructions, will be charged at full price for the service. No refunds will be given due to allergic reactions as that is something out of mine and your control.
If the persons receiving services is under the age of 18 years, we require Parents/Guardians permission and signature to perform services.
You hereby assume all risks of having eyelash extensions applied and agree to release, indemnify, defend, and forever discharge the releasee from all liability, claims, demands, damages, costs, expenses, and causes of action.
Appointment
I verify that the information I have provided on this form is truthful and accurate.
Date
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Month
-
Day
Year
Date
Client Signature
Submit
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