Eyelash Extension Consent Form

Name

First NameLast Name

Date of Birth

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

I grant permission to Lvlashbae_ to use my before and after photos for marketing or examples of my technicians work. *We will make you look GLAM!*

Please be as accurate as possible when filling in the following information

Rows	Yes	No
Lasik Eye Surgery
Permanent Eye Makeup
Blepharoplasty (eye lift)
Microdermabrasion
Allergies to adhesives/synthetics
Blepharitis (inflammation of eyelids)
Alopecia
Thyroid diseases
Allergies to Glycerin
Iron Deficiency
Recent High Fever/Severe Illness
Hypersensitivity to cyanoacrylate or formaldehyde or certain adhesives?
Vitamin and mineral deficiencies that may contribute to hair loss: A, F, B, Selenium, Zinc, Iron
Eye Illness or Injury
Eating Disorders
Dry Eyes
Seasonal Allergies
Oral Contraceptives
Hormonal Imbalance/Extreme stress
Major Surgery within 120 days
Pregnancy within last 120 days
Child birth within last 120 days
Triochillomania (hair pulling disorder)
Allergies to adhesives found in band-aids or medical tape
Do you use medication that can cause temporary hair loss such as, chemotherapeutic agents, Accutane, Retin A, Anticoagulants, Beta-adrenergic blockers, etc.

I agree that all the above information is true to the best of my knowledge.

Initial

Do you have frequent eye irritation, itching, or watery eye?

Do you wear contacts?

Do you wear glasses?

Have you had any type of eye surgery within the last 6 months?

Are you able to lay on your back for 2+ hours to have your lashes applied?

Have you ever had eyelash extensions applied before?

If yes, why and when did you remove them?

Do you use any of the following products on your lashes?

Other

Do you use any of the following products to your lashes?

Other

By signing below, you agree to the following:

I have provided truthful and accurate information on this form to the best of my knowledge. I agree to waive all liabilities toward my technician and the employer for any injury or damages incurred due to any falsification of my medical history

Date

Client Name (Printed)

Signature

I understand there are risks associated with having artificial eyelashes applied to and/or removed from my existing eyelashes, and that not withstanding the utmost of care in the application or removal of these products, there still exist risks associated with the procedure and product itself, which include, without limitation, eye irritation, eye pain, discomfort, and, in rare cases, blindness when improperly handled. As part of this procedure, I understand that a certain amount of eyelash adhesive material will be used to attach the artificial lash to my existing eyelashes. Even though the Professional may apply or remove my lashes properly, I understand adhesive material may become dislodged during or after the procedure, which may irritate my eyes or require further follow-up care, at my own expense to prevent damage to my eyes. I also understand there is more than one technique for applying lashes to my eyelashes, and I will not attribute any liability to the Eyelash Professional as a result of this procedure or the use and care of these lashes. I also agree to defend, indemnify and hold harmless the Eyelash Professional from any and all claims, actions, expenses, damages and liabilities, including reasonable attorneys' fees which might be asserted against them as a result of my having this procedure performed.

Initial

I acknowledge and understand that Lvlasbae does not do refunds. The lash tech will do the best of her abilities to satisfy the customer.

Initial

I agree to follow the care and maintenance instructions provided by Eyelash Professional for the use and care of my eyelash extensions, and that if any follow up care is required due to my own mistake or negligence, or failure to follow these instructions, this will be at my own expense and risk. I understand that if I do any of the following, it may result in damage to my eyelash extensions or may cause my lashes to fall off prematurely. Knowing this I agree to follow these tips for best results: I will avoid oil based eye products as these will loosen the bond of my eyelash extensions. For the first two days after application I understand it is best to avoid swimming, saunas or steam rooms. If I experience any itching or irritation, l agree to contact my Eyelash Professional immediately to have the lash extensions removed. I agree to avoid using waterproof mascara and to not use an eyelash curler, perm, or tint my eyelash extensions. I agree to not pick, pull or rub my eyelash extensions. I understand that I should not attempt to remove my lash extensions on my own or with any product, but that the procedure requires that my lash extensions be professionally removed.

Initial

I have read and completed the client intake form in its entirety and in truth. I acknowledge that I have been advised of the potential harmful or negative side effects (such as the premature shedding of my eyelash) that the lash extension procedure or removal may cause to those who have specific medical or skin conditions. I understand that the adhesives and adhesive remover are a skin, eye and mucus membrane irritant and that in rare cases persons may be allergic or have hypersensitivity to synthetics, cyanoacrylate or formaldehyde which in small amount may be present in the adhesive. I understand that the procedure requires that I lay still for up to 2 hours or longer with my eyes shut, and that if I wear contacts, I must remove my contact lenses for the duration of the lash extension application or removal. I further state that I have no known medical condition that might be aggravated by the procedure or any medical condition that would prevent me from complying with or heeding to the professional's instructions or these warnings.

If any action is brought to enforce the terms of this Agreement, the prevailing party shall be entitled to its costs and reasonable attorneys fees. Any claims arising out of this agreement will be resolved through binding arbitration using the rules of the American Arbitration Association. This agreement will remain in effect for this procedure, and all future procedures conducted by the Professional.

l agree that this Agreement is binding upon me, and my heirs, legal representatives and assigns. I represent that I am over 18 years of age and that I have the right to enter this agreement, or if I am under 18 years of age, I have had my parent or legal guardian consent to this agreement, and his or her relationship to me is as follows:
field. By his or her signature below, he or
she ratifies and consents to this procedure under these terms.

Client Initial

Thank you giving us the time to get to know YOU & signing the Consent form, its much appreciated towards your lash experience!

Date

Client Name (printed)

Signature

Eyelash Extension Waiver & Consent Form

Client Medical History

Additional Questions

Eyelash History

Waiver of Liability