Lash Extensions Consent Form
Must be completed before arriving to your appointment
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Are you 18+? (16/17 requires parental consent and signature)
Yes
No
Certain conditions may affect lash retention/growth, how frequent a fill appointment may be required and whether or not you are a good candidate for eyelash extensions. Please check the following conditions that apply to you
Glycerin allergy
Latex allergy
Allergy or hypersensitivity to formaldehyde, cyanoacrylate or adhesives/glues
Currently pregnant
Recent childbirth
Hormonal imbalance
Recent eye surgery
Recent major surgery
Use of retinoids (e.g. Accutane or Retin-A)
Use of drugs that cause hair loss
Chemotherapeutic agents
Iron deficiency
Permanent eye makeup
Dry eyes
Sensitive eyes
Watery eyes
Alopecia
Antibiotics
Claustrophobia
Extreme stress
None
Any other conditions not listed?
Please list any eye medication or drops you are currently using:
Is this your first time applying eyelash extensions?
Yes
No
Do you wear glasses or contacts?
Glasses
Contacts
Both
None
Please read and check the following statements
I understand the importance of disclosing my health history and other requested details on the Client Information Form and have not withheld any conditions which may affect this procedure.
I understand that synthetic eyelash extensions will be applied to my natural lashes with glue during this service.
I understand that the technician will apply the eyelash extensions to my natural lashes in such a way to prevent any damage and maintain the health of my lashes. As a result, my desired look may not be achieved.
I understand that I am required to lie still with my eyes closed for up to 3 hours or more during the appointment. Opening my eyes prematurely can expose them to the fumes from the adhesive and cause a reaction.
I understand the risks associated with this procedure may include, but are not limited to, itching, redness, irritation, allergic reaction and potential blindness (rare).
I understand that my natural lashes will grow and fall out naturally. In order to replace the fallen lashes and maintain the original look, a fill appointment will be required (usually every 2-3 weeks).
I understand that should an allergic reaction occur, I will contact the technician immediately to arrange for the removal of the extensions. I will also seek medical attention from a physician at my own expense. I understand that no refund for the initial service will be provided.
I will follow the aftercare instructions provided by the technician and not attempt to remove the extensions on my own.
I understand that the adhesive remover used during removal of the extensions may contact my eye and cause a reaction that may require medical attention at my own expense
I agree to have photographs and videos taken of myself before, during, and after the procedure. I grant permission for my image or likeness to be used for marketing and other purposes including display on social media accounts or a website. I also agree to any image retouching required by the technician. I assign any copyright in the photographs or video to the technician.
l agree to defend, indemnify and hold harmless the technician below from any and all claims, actions, expenses, liabilities and damages, including reasonable attorney fees, which may be asserted against the technician due to this or future procedures or purchase of any products.
I agree to follow all Anh Lash House (Anh Nguyen) policies posted on anhlashhouse.com/care-policies
By signing below, I certify that I have read and fully understand the above statements and have had adequate opportunity to have any questions or concerns addressed. I understand the procedure and accept the risks. I understand that this agreement is legally binding. I confirm that I am over the age of 18, of sound mind and fully capable of executing this waiver for myself. (Parental consent will be required if under 18 years old.) This agreement will remain in effect for this procedure and all future procedures provided by the technician below.
Parent/Guardian Signature (If 16/17 years of age)
Submit
Submit
Should be Empty: