Eyelash Extension Consent Form

Eyelash Extension Consent Form
Customer Details:
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail
example@example.com
Medical History:
Do you currently have or have you had any of the following medical conditions? If yes, please check all that apply:

AllergiesGlaucomaDry Eye SyndromeRecent Eye SurgeryConjunctivitis (Pink Eye)BlepharitisEye AllergiesDiabetesOcular HerpesEye InfectionsCataractsRetinal DisordersCorneal ConditionsEpilepsySevere Eye Sensitivities
Do you have any known allergies or sensitivities to lash extension adhesives or products

YesNoI don't know
Have you had any eye or eyelid surgery in the past six months?

YesNo
Do you use any lash serums or growth enhancers on your natural lashes?

YesNo
Eyelash Extension Conscent Form:
Have you ever had eyelash extensions before?

YesNo
I, blanks, certify that the information provided in this form is accurate and complete to the best of my knowledge. I have read, understood, and answered all questions truthfully. I have discussed any concerns or questions with the lash technician, and I have read and understood the aftercare instructions provided to me. I agree to inform the lash technician of any changes to my medical history, eye conditions, or concerns. I will not hold the salon or technician responsible for any issues not disclosed at the time of my service or any adverse effects from the lash extensions procedure.
I, blanks, hereby consent to the application of eyelash extensions by mInk & Beauty by Arlene, I understand the procedure involves the attachment of individual synthetic, silk, or mink lashes to my own natural lashes using a semi-permanent adhesive.

I understand that the purpose of this procedure is to apply eyelash extensions for cosmetic or personal reasons.

I acknowledge that there are certain risks associated with this procedure, including but not limited to eye irritation, allergic reactions, and complications related to the lash extensions.

I release Arlene Kamalatisit / Ink & Beauty by Arlene or other technicians, from all liability for any injury, harm, or adverse reactions claimed by me or anyone on my behalf due to the eyelash extension procedure or the conduct of the eyelash technician. I have been provided with information regarding the eyelash extension procedure, its purpose, risks, and aftercare instructions.

I agree to follow the aftercare instructions provided by the technician to maintain the quality and longevity of the lash extensions. I have had the opportunity to ask questions, and all my concerns have been addressed to my satisfaction.

I understand that the results of this procedure may vary depending on individual factors.

I consent to the eyelash extension procedure and acknowledge that the decision to proceed with this procedure is voluntary.

I understand that I can withdraw my consent at any time before the procedure begins. This agreement remains in effect for this procedure and any follow-up appointments.
Signature

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