Eyelash Extensions Consent Form

  • Eyelash Extensions Intake and Consent Form

  • Personal Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
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  • Lash Information

  • Is this the first time you're having lash extensions applied?
  • Are you having lash extensions applied for:
  • Do you wear contact lenses or glasses?
  • Do you habitually rub, pull, or pick your lashes for any reason?
  • Do you have, or are being treated for, any eye illness or injury?
  • Are you able to keep your eyes closed, avoid talking and lie still for up to 2 hours or longer?
  • What position do you sleep?
  • Please check off any of the following that might apply to you:

  • By signing below, you agree to the following:

    I have completed this form to the best of my ability and knowledge and agree to inform the technician of any changes in the above information. / have been informed of and understand the contraindications to the requested treatments and agree that / do not have any condition(s) that would make the requested treatment unsuitable. / will inform the technician of any discomfort / may experience at any time during my treatment to allow them to adjust accordingly. / agree to waive all liabilities toward my technician and the employer for any injury or damages incurred due to any misrepresentation of my health history.

  •  / /

  • *Note: Your privacy is important to us. We will not sell or share your personal information with third parties, unless required by law* 

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  • Eyelash Extensions Intake and Consent Form (Continued)

  • *Please initial*

  • Please mark:
  • Preferred correspondence:
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  • Should be Empty: