Eyelash Extension Consent Form
Name
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Health History | Please check any of the following that applies to you
Allergy to adhesives band aid or medical tape
Allergy to surgical glue or nail glue
Seasonal allergies
Eye illness or injury
Blepharitis (inflamed eyelids)
Permanent eye-makeup
Other
Have you ever had eyelashes extensions before?
Yes
No
If no, we would you like to have a patch test which we highly recommend? (Note that a patch test does not guarantee that an adverse reaction will never happen)
Yes
No
Please agree to the terms and conditions
I hereby agree to have eyelash extensions applied to my natural lashes and consent to the placement and/or removal of the eyelash extensions by Lash Habit Academy and it's associates.
I understand and agree to the after-care instructions and for any unexpected circumstance that have happened due to not following these instructions are in my own risk.
I understand that in rare occasions there are risks associated with having artificial eyelashes. I further understand that in rare circumstances eye or skin irritation and discomfort may occur.
I understand that because of the natural lash cycle and wear and tear, I will need to maintain my extensions with touch up appointments usually recommended about every 2 to 3 weeks to keep them full.
I agree to have my photo/ video taken and posted on social media.
I agree to the risks and understand there will be be no refund given to me if I experience a reaction or don’t Ike the way the extensions look on me.
Date
-
Month
-
Day
Year
Date
Client Signature
Student/Technician Name
First Name
Last Name
Student/Technician Signature
Submit
Submit
Should be Empty: