Lash Consent Form
Name
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First Name
Last Name
Email
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example@example.com
Phone Number
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-
Area Code
Phone Number
Date
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Month
-
Day
Year
Date
Have you had any allergic reactions to lash extension in the past? When?
I understand that lash extension have some inherent risk of irritation to the orbital eye area, including the eye itself, and could result in stinging and burning, blurry vision should the adhesive enter the eye or should an allergic reaction occur.
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Agree
I understand that this is a semi-permanent procedure, as my natural lashes will continue to grow and fall out normally, making touchup or “fill” appointments necessary to maintain the original look achieved by replacing the lashes that have fallen out. Most clients require a fill appointment every 2-3 weeks
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Agree
I consent to “before and after” pictures for the purpose of documentation, potential advertising and promotional purposes.
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Agree
I understand that if I have any concerns, I will address these with my technician. I give permission to my technician to perform the lash extension procedure we have discussed. I also consent to “before and after” pictures for the purpose of documentation, potential advertising and promotional purposes. I give permission to my technician to perform the lash extension procedure we have discussed, and will hold him/her and his/her staff harmless and nameless from any liability that may result from this treatment. I have accurately answered the questions above, including all known allergies, prescription drugs, or products I am currently ingesting or using topically. I understand my lash extension specialist will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult the lash extension specialist immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the lash extension specialist responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today.
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Yes
I understand at Mala Winks Salon I am paying for my lash technician time & skill therefore agreeing to their policy that they do not offer refunds.
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I agree
Signature
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Submit
Submit
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