KDLUXELASHES
Consent Form
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Health History| Please check any that apply to you
I agree to reschedule my appointment if I have l experienced any illness
Eye illness or injury
Allergy to adhesive band aid or medical tape
Are you allergic to acrylate/ cyanoacrylate (bonding agent) ?
Use contact lenses
Pregnancy
Is there any other condition or significant information I need to know about that may affect you during or after this procedure?
Please agree to the terms and conditions
I agree to have eyelash extensions applied to my natural lashes
I understand i will be asked to come alone
I understand the aftercare instructions and not following these instructions are at my own risk
I understand it is my responsibility to keep my eyes closed during the procedure until instructed otherwise
I understand that some risks of this procedure may include limited eye redness and irritation due to the fumes from the adhesive
I give permission to share my before and after photos to all forms of social media
I have read, completed, and agree to this consent from in its entirety, and have answered everything to the best of my ability. I have been informed of potentially harmful or negative effects that could be caused by the application/ removal procedure
Signature
Submit
Submit
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