Eyelash Extension Consent Form
Name
First Name
Last Name
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Lash Technician
Christina Windle
Hannah Ray
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
Allergy to glycerin
Eye illness or injury
Blepharitis (inflamed eyelids)
Permanent eye-makeup
Eye lift
Drugs that can cause temporary hair loss
Major surgery within last 120 days
Other
Please agree to the terms and conditions for Individual Lash Extension
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 the certified professional.
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.
Please agree to the terms and conditions for Semi Permanent Lash Extensions
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 the certified professional.
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 10 to 14 days to keep them full.
Release of Liability Waiver
I read English and 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 treatment. I release my technician from all liability associated with this procedure, which is performed with the utmost attention to safety and proper application using tools and products that the technician has been professionally trained to use. There are no guarantees for length of time the lashes will stay permed. I understand the aftercare instructions and will do my part to maintain my eyelashes. I understand that there are many factors that may affect the life of the eyelash lift such as water and moisture contact, weather conditions, and activities involving exposure to high temperatures. By signing below, I verify that I have read and understand the above statements and agree to them.
Permission is granted to take photos of my eyes / face which may be used for marketing purposes on a website or for client records.
Date
-
Month
-
Day
Year
Date
Client Signature
Technician Name
First Name
Last Name
Submit
Submit
Should be Empty: