Eyelash Extension Consent Form

EYELASH EXTENSION CONSENT FORM
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Email
Date of Birth

MonthDayYear
mm-dd-yyyy
How did you hear about us?

Other
Social media handles
Instagram, Facebook
Please list any known allergies:
Including adhesives, glues, tapes, bandaids, etc. or N/A
Emergency Contact

Full NameCell Number
Our Policies

Please take a moment to complete our consent form. By submitting the form below you agree to knowingly and willingly consenting to our policies and procedures.
24- hour notice is required for any canceled or rescheduled appointment or up to 100% of service price will be charged. Failure to show without notice will require in full payment of service booked. We do not offer monetary refunds on services rendered. We do have a 7-day policy in place on services in which a client can come back and have corrections made provided we are notified of issues within 24-48hours of the service. Client must contact provider within 24-48hours after service rendered of any issues. Fees may apply. By choosing yes, I’m acknowledging I have read, understand, and agree with the terms of these policies.
Have you undergone chemotherapy within the last 6 months? Medication for chemotherapy may cause a reaction to the materials used for eyelash extensions.
Are you currently taking Thyroid medications? These medications can change the environment of the lash area making natural lashes oilier, dryer or more brittle.
Have you recently had Lasik surgery within the last 3 months? Eyes must be fully healed with a doctors note.
Do you wear contact lenses? Adhesive fumes may get underneath the contact lens and cause corneal abrasion or scratching. Contact lenses must be removed prior to eyelash extension procedures.
Do you have oily skin? Natural oils will break-down the adhesives used to bond the eyelash extensions causing the eyelash extensions to fall out.
I understand that the eyelash extensions will be applied to the natural lash as determined by the technician so as not to create excessive weight on the natural eyelash thereby preserving the health, growth and natural look of the client’s natural eyelashes.
I understand as part of the procedure eye irritation, eye itching, discomfort and in rare cases eye infection may occur.
I understand and agree that if I experience any of these issues with my lashes that I will contact my technician and have the eyelashes removed immediately and consult a physician at my own expense.
I understand that even though the technician may apply and remove the eyelashes properly, that adhesive materials may become dislodged during or after the procedure, which may irritate my eyes or require further follow up care.
I understand and agree to follow the after care instructions provided by my technician. Failure to follow the after care instructions can cause the eyelash extensions to fall out prematurely.
I understand that in order to have the eyelash extensions applied to my eyelashes I will need to keep my eyes closed for duration of 2.5 - 3.5 hours during the procedure. I also understand that I will need to be lying in a reclined position. Any medical conditions that might be aggravated by lying still for a prolonged period of time may mean I may not be a good candidate for lash extensions.
If photos/videos are taken, I give consent to the use of my before/after photos/videos for marketing and social media purposes.
This agreement will remain in effect for the procedure and all future procedures conducted by my technician for one year from the date of this signed form. I understand that this agreement is binding and that I have read and fully understand all information listed above. I represent that I am over the age of 18 years. If below 18 years of age a parent or guardian must also sign this form.
Signature
Parent Signature if client under 18years of age
Should be Empty:

EYELASH EXTENSION CONSENT FORM

Our Policies