Eyelash Extension Consent Form
Client Name
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First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Have you had eyelash extensions applied in the past?
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YES
NO
Do you wear contact lenses?
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YES
NO
Do you have, or are you being treated for any eye illness or injury? If yes, please explain.
*
Please check any of the following that might apply to you:
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Lasik Eye Surgery
Allergies to adhesives or synthetics
Allergies to glycerin
Hypersensitivity to cyanoacrylate or formaldehyde or certain adhesives/glues
Recent high fever or severe illness
None of the above
Please list any known allergies:
*
Disclosure
Although every precaution will be taken to ensure your safety and wellbeing before, during, and after your lash extension application, please be aware of the following information and possible risks. Please initial:
I understand that a full set of lash extensions can make the appearance of my own lashes about 30-50% thicker, and make my lashes appear 20-50% longer.
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I understand that lash extension services have some inherent risk of irritation to the orbital eye area, including the eye itself, and could result in stinging or burning, and blurry vision should the adhesive enter the eye or should an allergic reaction occur.
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I understand that some irritation, itching, or burning may occur on the skin if the bonding agent comes into contact with the skin.
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I understand that if the bonding agent comes into contact with my eye, my eye will be flushed with water and I will be assisted in seeking medical attention immediately.
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I understand that this is a semi-permanent procedure, and my natural lashes will continue to grow and fall out normally, making touch-up 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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I understand that while every attempt will be made to provide me with the length and fullness I have chosen, my final result may not be what I initially envisioned.
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I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications.
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I understand that additional conditions could occur or be discovered during the procedure which could affect my ability to tolerate the procedure.
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I agree to follow the care and maintenance instructions provided by Grace Waxing Co for the use and care of my lash extensions, and that if any follow up care is required due to my own mistake or negligence, or failure to follow these instructions, this will be at my own expense and risk. I understand that if I do any of the following, it may result in damage to my lash extensions or may cause my lash extensions or natural lashes to fall out prematurely. Knowing this I agree to follow these tips for best results: I will avoid oil based eye products as these will loosen the bond of the lash extension adhesive. I will avoid getting my lashes wet within the first 24 hours after application. For the first 24 hours after application I understand it is best to avoid swimming, saunas or steam rooms. If I experience any itching or irritation, I agree to contact Grace Waxing Co immediately to have the lash extensions removed. I agree to avoid using waterproof mascara and to not use an eyelash curler, perm, or tint my lashes while wearing lash extensions. I agree to not pick, pull or rub my lash extensions. I agree to wash my lash extensions at home with a lash extension specific cleanser to remove dirt and oil build up to best protect my lash extensions and keep my natural lashes as healthy as possible. I understand that I should not attempt to remove my lash extensions on my own or with any product, but that the procedure requires that my lash extensions be professionally removed.
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I consent to "before" and "after" photographs for the purpose of documentation, potential advertising and promotional purposes.
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YES
NO
I understand that if I have any concerns, I will address these with my lash extension specialist. I give permission to my lash extension specialist 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 Grace Waxing Co or the lash extension specialist, whose signature appears below, 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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Lash Extension Specialist Signature
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