Eyelash Extension Intake & Consent Form

Name*

Date of Birth*

Date

Address*

City*

State*

Zip Code*

Phone*

Email*

example@example.com

Have you had eyelash extensions in the past?*

YesNo

If yes did you have any issues Please explain

My desired look for eyelashes*

I agree to have eyelash extensions applied to my natural eyelashes and/or removed and retouched. By signing this agreement, I consent to the placement and/or removal of the eyelash extensions by the certified eyelash extension professional. Although every precaution will be taken to ensure my safety and wellbeing before, during, and after my lash extension application, I am aware of the following information and possible risks. Please click yes to all below to confirm:

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.

I understand that this is a semi-permanent procedure, as my natural lashes will continue to grow and fall out normally, makingtouch-up or “fill” appointments necessary to maintain the original look achieved by replacing the lashes that have fallen out.

I understand that while every attempt will be made to provide me with the length and fullness I have chosen, my final result maynot be what I initially envisioned

I consent to “before and after” photographs for the purpose of documentation, potential advertising, and promotional purposes.

I agree that if I experience any ill effects with my lashes that I will contact the certified eyelash extension professional thatperformed this procedure.

I understand that if I experience ill effects it may be beneficial to have the eyelashes removed

I understand and agree to the after-care instructions provided by the certified eyelash extension professional for the use andcare of my eyelash extensions. I realize and accept the consequences of failure to adhere to these instructions and I understand that it maycause the eyelash extensions to fall out and/or decrease the time the lashes will last.

I understand and consent to have my eyes closed and covered for the duration of an approximately 60-120 minute procedure. Iunderstand that times may vary depending on the type and number of eyelashes applied

I understand that in order to apply a lash extension to each individual lash that I need to remain calm and quiet to keep my facial muscles relaxed as possible. I will notify the therapist if I need to move or adjust.

I understand that lashes will need to be filled on a routine schedule. Cost for fills are based on the time length in-betweenappointments. Appointments beyond 3 weeks will be charged at the current full set rate.

I understand that I will need to keep my lashes clean, using an oil-free cleaner for the best results in maintenance.

I understand that if I come to my appointment with an excessive amount of lashes missing (picking, poor home care) that my fill price may be increased from 1-2 week fill to a 2-3 week fill price.

I am informing the certified eyelash extension professional of the following conditions that apply to me. (Check all that apply)

I currently use contact lenses (Which I may be asked to remove during the procedure)I currently use products such as oil-containing sunscreen or moisturizers around my eyesI have a history of recurrent eye or tear duct infections.I have a history of dry eyes or Sjögren's syndromeI have a recent history of ChemotherapyI have other medical conditions which would prohibit or compromise placement and retention of eyelash extensions.

I am taking the following medications and/or supplements

I have the following allergies or sensitivities.

This agreement will remain in effect for this procedure and all future follow-ups conducted by the certified eyelash extension professional. I understand that this consent agreement is legal and binding. I have read and fully understand all information in this agreement. I am over 18 years of age and consent to the agreement and to the eyelash extension application procedure.

Signature*

Date*

Date

ParentGuardian Name Printed

ParentGuardian Signature

Eyelash Extension Consent & Intake Form