Eyelash Extension Consent Form & Waiver of Liability

Name*

First NameLast Name

Appointment Date*

Date

Date of Birth*

Date

Phone Number*

Please enter a valid phone number.

Email

example@example.com

Have you had eyelash extensions and/or lash lift & tint before?*

YesNo

If yes, what type and was there any discomfort during or after the procedure?

If no, we recommend a patch test. Please initial if you are *opting out* of the advised adhesive patch test. *

Please initial that you understand that a patch test does not guarantee that a adverse reaction will not happen.*

Have you had any allergies or an allergic reaction?*

If yes, please clarify...

Do you have or had any of the following ?*

Allergies to Adhesives (glues, tapes, band aids, etc.)Chemotherapy Treatments within the last 6 months?Thyroid/ Hormones MedicationsLasik Surgery less than 4 months (must wait 4 weeks post-op exam for medical consent)Blepharoplasty (must wait 6 months post-op for medical consent)Sensitive and/or sensitized skinCurrently pregnantHad a lash lift within the past 4 weeksNONE OF THE ABOVE

Please add anything else you may seem appropriate that could affect having eyelash extensions and/or lash lifts & tint.

Please read each statement and acknowledge by checking each box:*

As part of the removal procedure, I understand that a certain amount of chemical adhesive remover is applied to exsiting adhesives and a reaction occurs to dissolve the adhesive that results in thinning of the remover. Even though the eyelash extension artist may apply or remove my eyelash extensions in the usual manner, I understand the liquid remover may seep into my eyes, which may irritate my eyes or require further follow up care, at my own expense to prevent damage to my eyes. I also understand that if I can also experience this with the application of lash perming and tinting products in its application and/or removal process.

The agreement will remain in effect for this procedure and all future follow ups conducted by the certified eyelash enhancement professional. I read English and understand that this consent agreement is legal and binding. I have read and fully understand all information in this agreement and hereby release any and all persons representing this salon from all claims, demands, damages, actions and cause of action arising out of ther performance of the service. I have fully disclosed all condtions regarding my health history, medications and past reactions to products, treatments and medications. I am over 18 years of age and consent to the agreement and to the eyelash extension application procedure.

Signature*

Today's Date*

Date

Eyelash Extension Consent Form & Waiver of Liability

WAIVER & RELEASE OF LIABILITY

LASH APPOINTMENT POLICIES