Eyelash Extensions Intake & Consent Form
Earth & Beauty
Full Name
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First name
Last name
Cell Phone Number
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Format: (000) 000-0000.
Email
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example@example.com
I grant permission to Earth & Beauty to use my before and after photos for marketing or examples of their work.
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Yes
No
I release Earth & Beauty from any and all liability associated with this procedure. This service will be performed with the utmost attention to safety, sanitation, and proper application using tools and products that the technician has been trained and certified to use. This service has many variables due to lifestyle, moisture, weather, extreme temperatures, natural eyelash shedding and other factors. The technician will decide if I am a good candidate for this service to the best of their ability.
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Initial
I acknowledge and understand that the studio doesn’t offer refunds. Earth & Beauty will do their ultimate BEST to provide a service experience to meet your satisfaction and expectations to LOVE your lashes every appointment. However if you are unhappy with your lashes/service please reach out within 72 hours from your appointment for a complimentary touch up.
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Initial
I acknowledge Earth & Beauty does their full effort to fulfill my appointments times and I respectfully acknowledge the times I schedule to be available. Any appointment CANCELLED with less than a 24 hour notice from scheduled appointment time will not be issued a refund of deposit. Second cancelation offense, you will be charged 40% fee of your appointment total. If you cancel often you will be no longer able to book with Earth & Beauty. While things may happen, we advise appropriately booking.
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Eyelash extensions require on-going maintenance (similar to a nail service). Refills are recommended approximately every 2 to 3 weeks. For it to be considered a fill appointment, you must come in with at least 40% of your lashes still intact. I understand if I go beyond this recommended time it will be charged as a full set.
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Initial
Is this your first time having Eye-lash Extensions?
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Yes
No
Do you wear Contacts?
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Yes
No
Do you often rub, pull or pick your lashes for any reason? Please note touching or rubbing your eyes could result in damage to the natural lashes.
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Yes
No
Do you have a severe eye illness or are you being treated for an eye injury?
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Yes
No
How do you usually sleep? Please note, you will lose more eyelash extensions on the side on which you sleep. Sleeping on your stomach will affect them the most. It is important to refrain from sleeping on your stomach for the first 2 days after your service to allow the adhesive to set properly.
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Side
Stomach
Back
Are you able to lay on your back for 2 - 3 hours to have your lashes applied?
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Yes
No
Are you pregnant?
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Yes
No
It is also recommended to avoid all oil-based products around your eyes for as long as you wear your lashes. Oil based products, mascara, eyeliner and eyeshadow will loosen the adhesive and your lashes will not last. Please come to your appointments with no eye-makeup.
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Please initial you read and understand the above.
The following conditions are not suitable for eyelash extensions. Possible adverse reactions are listed below each condition
Are you allergic to adhesives (glues, tapes, band aids, etc)? This service may use adhesives tapes, glues and gel pads that may cause an allergic reaction. If yes, please state what you are allergic to.
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No
Yes
Have you had Chemotherapy treatments in the last 6 months? Medication for chemotherapy may cause a reaction to the materials used in this service. Also, if lashes are just starting to grow back they may be a little weak and we recommend waiting until they are strong enough for this service.
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Yes
No
Have you had Lasik Surgery in the past 4 months? Eyes may have sensitivity to eyelash extensions and products used for prepping the eye area. (gel pads, glues, etc.)
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Yes
No
Are you currently taking Thyroid Medications? Thyroid medications or Thyroid conditions may not have lash extensions last long due to either of these
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Yes
No
Blepharoplasty or other eye condition or surgery in the last 6 months? Blepharoplasty, eye surgery or conditions may have sensitivity to eye-lash extensions and products used. Consult your doctor first and ask if it's safe for you to have this service
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Yes
No
I agree and understand that Earth & Beauty has no way of knowing if the client is allergic to some of the products or materials being used in any eye-lash procedure, though we do use sensitive eye products to ensure comfort every client is different. Earth & Beauty does offer patch tests to those that are not sure if they are a good candidate and will help to discuss options. I will seek medical care (at my own expense) and contact my technician immediately if any allergic or adverse reaction occurs. All of my questions were answered and I understand the procedure and risks.
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Initial
Thank you giving us the time to get to know YOU & signing the Consent form, its much appreciated towards your lash experience!
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By signing below, I verify that I have read and understand the above statements and agree to have answered medical questions honestly to my knowledge.
Sign date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Client signature
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I'm Ready Queen!!
I'm Ready Queen!!
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