Eyelash Extension Consent Form
Thank you for choosing Simply Wonderful Nails. Please complete the following consent form prior to your appointment.
Name
*
First Name
Last Name
Phone Number
*
Email
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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 cyanoacrylate
Eye illness or injury
Blepharitis (inflamed eyelids)
Permanent eye-makeup
Drugs that can cause temporary hair loss
Major surgery within last 120 days
Other
Please agree to the terms and conditions
*
I here by 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 eyelash technician.
I understand that it is my responsibility to keep my eyes closed and be still during the entire procedure, until my eyelash technician addresses me to open my eyes.
I understand that some risks of this procedure may be but not limited to eye redness and irritation. The fumes from the adhesive may case my eyes to tear up if I open my eyes.
I agree to disclose any allergies that I may have to latex, surgical tape, cyanoacrylate, vaseline, etc.
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 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.
I agree thatI have read and fully understand this entire consent form.
I am of sound mind and fully capable of executing the waiver for myself.
I agree that by reading and signing this consent form, I release my lash technician and Simply Wonderful Nails from any claims or damages of any nature.
By signing here you confirm that all the information provided is correct and agree to all the terms and conditions
*
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