Eyelash Extension Consent Form

Name

First NameLast Name

D.O.B

Date

Address

Street Address

Street Address Line 2

CityCounty

Post Code

Phone Number

Please enter a valid phone number.

Have you had a patch test?

YesNo

Have you received eyelash extensions before?

YesNo

Have you had permanent cosmetics applied to your eye area?

YesNo

Do you wear contacts?

YesNo

Do you have or are you being treated for any eye illness or injury?

YesNo

Are you able to lay on your back for 2+ hours to have your lashes applied?

YesNo

Are you pregnant?

YesNo

Are you allergic to adhesives (glues, tapes, plasters, gel pads etc.)?

YesNo

Have you had eye Surgery in the past 4 months?

YesNo

Disclaimer

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 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, Vaseline, etc.

I have also had the opportunity to decline a patch test and say I do not wish to have the patch test before the treatment is carried out.

PUBLICITY MATERIALS I authorise the taking of clinical photographs and videos. I understand that photographs and video may be taken of me 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.

Signature