• Lash Extensions Health History & Consent Form

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • How did you hear about us?

  • Your Medical History

  • Have you ever had a reaction to adhesive tape, topical creams, nail adhesives, or other topical products?*
  • Do you have any eye diseases, conditions, or injuries that have affected your hair/lash growth or loss?*
  • Please indicate if you have ever had any of the following conditions: (Check all that apply)*
  • Are you pregnant or nursing?*
  • Do you wear contacts?*
  • Do you wear glasses?
  • Do you use Retin-A or Accutane?*
  • Have you had facial treatments?
  • Have you ever had lash extensions?
  • Have you ever had lash extensions removed?
  • Do you go tanning (in salon, outdoor, or spray tan?)*
  • Have you ever used long-lasting waterproof cosmetics?
  • Have you ever had Botox®, Juvederm®, or any other injectables?
  • I consent to “before and after” photographs for the purpose of documentation, potential advertising and promotional purposes.*

  • I acknowledge that I must adhere to the policies. I understand all services require a non-refundable deposit of $20. The deposit will be credited towards my appointment. I agree to arrive 10 minutes prior to my appointment.

    I understand that cancellations or rescheduling an appointment must be done with at least 24 hours notice. Failure to attend without prior notice will require a deposit fee to secure my next appointment. I understand that after 15 minutes of tardiness, my appointment may be subject to cancellation, and I will be responsible in accordance with the “No-show” policy. Tardiness may also result in shortened service time and full service charge.

     

    I have agreed to have eyelash extensions applied and/or removed from my eyelashes. Before my qualified lash technician can perform this procedure, I understand I must complete this agreement and provide my consent by signing and dating this digital form.

    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.

    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 and burning, blurry vision and potential blindness should the adhesive enter the eye or should an allergic reaction occur.

    I understand that some irritation, itching or burning may occur on the skin if the bonding agent comes into contact with it.

    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. If I choose to consult a physician, it will be at my own expense.

    I understand that this is a semi-permanent procedure, as 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.

    I understand that there are many factors that may affect the life of the eyelash extensions such as water and moisture contact, weather conditions, and activities involving exposure to high temperatures.

    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.I understand that it is imperative that I disclose all of the information requested in the Client Profile/Health History.

     

     

    I give permission to my lash extension specialist to perform the lash extension procedure we have discussed, and will hold her harmless and nameless from any liability that may result from this treatment. 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 release Em Beauty & Skin and service providers from all liability associated with this procedure and I will do my part to maintain the health of my eyes and eyelash extensions by following all aftercare instructions.


    I am over 18 years of age and consent to the agreement and to treatment or have a parent with me that consents to this service. 

    This agreement will remain in effect for this procedure and all future procedures conducted by my technician.

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