• New Client Eyelash Extension Consent Form

    I have agreed to have eyelash extensions applied and/or removed from my eyelashes. Before my qualified professional eyelash technician can perform this procedure, I understand I must complete this agreement and provide my consent by signing and dating this two page Consent Form where indicated below.The following conditions may determine that you are not suitable for eyelash extensions:

  • Check yes or no:

  • Are you allergic to adhesives (glues, tapes, band aids, etc.)? Eyelash extension services use adhesive tapes, glue and gel pads that may cause an allergic reaction
  • Have you had chemotherapy within the last 6 months? Medication for chemotherapy may cause a reaction to the materials used for eyelash extensions.
  • Do you take Thyroid Medications? Eyelash extensions will not last due to the medication.
  • Have you had Lasik Surgery less than 4 months ago(must wait 4 weeks post-op exam for medical consent)? Eyes may have sensitivity to eyelash extensions and products used for prepping the eye area (glues, gel pads).
  • Have you had a Blepharoplasty(must wait 6 months post-op formedical consent)? Eyes may have sensitivity to eyelash extensions and products used for prepping the eye area (glues, gel pads).
  • Do you wear Contact Lenses? Glue used to apply the eyelash extensions 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 excessive oily skin and hair?Natural oils will break down adhesives used to bond the eyelash extensions causing them to fall out.

  • Social Media Consent Opt-In:
  • I give consent to have my images posted on all social media platforms

  • I agree to the following:

  • I understand there are risks associated with having artificial eyelashes applied to and/or removed from my natural eyelashes.


    I understand that the technician will use their discretion in deciding how many eyelash extensions will be applied to my natural lashes so as not to create excessive weight on the natural eyelashes.


    I understand that as part of the procedure, eye irritation, eye pain, eye itching, discomfort and in rare cases eye infection, may occur.


    I understand and agree that if I experience any of the above issues with my lashes I will contact my technician, have the extensions removed immediately and consult a physician, all at my own expense.


    I understand that even when the technician applies and removes the eyelashes properly, 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 aftercare instructions provided by my technician. Failure to follow aftercare instructions may cause eyelash extensions to fall out.


    I understand that in order to have extensions applied to my eyelashes, I will need to keep my eyes closed for roughly 90-240 minutes during the procedure.

    I also understand that I will need to be lying in a flat or reclined position. Any medical conditions that might be aggravated by lying still for a prolonged period of time may mean I will not be able to have the procedure performed on my eyes.


    This agreement will remain in effect for the procedure and all future procedures conducted by my technician.
    I understand that it is my responsibility to notify my technician if any of the conditions mentioned above in this form are applicable to me in the future while I continue to have eyelash extensions done by my technician.

    I understand that this agreement is binding and that I have read and fully understand all information listed above. I confirm that I am over the age of 18 years. If below 18 years of age a parent or guardian must also sign this form*.

  • Format: (000) 000-0000.
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