EYELASH EXTENSION CONSULTATION AND CONSENT FORM

EYELASH EXTENSION CONSULTATION & LIABILITY RELEASE
Name:*

First NameLast Name
Email:*
example@example.com
Phone Number:*
Please enter a valid phone number.
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact:*
Name & Number
Allergies*

YesNo
If checked yes, please explain:
(latex, acrylates such as acrylic nails)
Asthma or any respiratory (breathing problems)*

YesNo
If checked yes, please explain:
(latex, acrylates such as acrylic nails)
Sensativities*

YesNo
If checked yes, please explain:
(latex, acrylates such as acrylic nails)
Medical Problems*

YesNo
If checked yes, please explain:
(latex, acrylates such as acrylic nails)
Are you pregnant or do you plan to be?*

YesNo
Prior eyelash extension procedure?*

YesNo
If checked yes, please advise the procedure/s and result:
(latex, acrylates such as acrylic nails)
Do you wear contact lenses?*

YesNo
Type of eye makeup remover & mascara?
brand and variety
Desired length and style of extensions:*
(natural, long, dramatic, cat eye, embellished, etc)
Sleeping on my face, extreme weather changes, steam, sauna, and other activities may damage the adhesive or crimp the extensions and may require more frequent refills. I reviewed and understood the aftercare instructions and will do my part to help maintain my eyelash extensions.
Initials*

Clear
I understand that eyelash extensions require ongoing maintenance (like a nail rebase) and that refill fees are based on time and/or the number of extensions that need to be replaced at the refill appointment. If I wait too long between refills, I may need to pay for a new full set. If I no longer wish to wear the eyelash extensions, my technician will remove them, and I will not try to remove them myself. There may be a fee for removal of eyelash extensions.
Initials*

Clear
I confirm I will not remove my eyelash extensions myself
Initials*

Clear
If any adverse or allergic reaction occurs I will seek medical care (at my own expense) and contact EN Signature Brows & Beauty Studio immediately.

All my questions were answered, and I understand the procedure and risks.
Initials*

Clear
I grant permission to the technician and EN Signature Brows & Beauty Studio to take before and after photos.

Before and after photos are a permanent part of the Technician's records. You may opt out of marketing purposes.
Initials*

Clear
I grant permission for the technician & EN Signature Brows & Beauty Studio to use my before and after photos for marketing purposes*

YesNo
I release the technician and EN Signature Brows & Beauty Studio from all liability associated with this procedure (which will be performed with the utmost attention to safety and proper application using tools and products that the Technician has been trained to use). This procedure has many variables due to lifestyle, moisture, weather, extreme temperatures, natural eyelash shedding, and other factors.

The Technician will assess and decide if I am a candidate for this service to the best of their ability. No guarantees are made or implied.
Initials*

Clear
By signing below, I verify that I have read and understand the above statements and agree to them.
Client Signature*

Clear
Date*

MonthDayYear
Date
Technician Signature *

Clear
Date*

MonthDayYear
Date
Thank you for the time you took to read, understand, and agree to our consent form.

Have A Beautiful Day!

Signature Brows & Beauty Studio

Office: 808-797-5757

"Your Beauty, Our My Signature".
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