Lash Extensions Consultation Form

Lash & Blowout Lounge Lash Extensions Consultation Form
Name
Birthdate

MonthDayYear
Date
Cell Phone
Format: (000) 000-0000.
Email address
example@example.com
Emergency Contact
Emergency Contact Cell Phone
Format: (000) 000-0000.
How did you hear about us
Do you have any of the following conditions (check all that apply):
Are you currently being treated for an eye illness or injury? Yes or No If yes please describe
Do you currently have irritated or itchy eyes?
Are you allergic to Latex or Acrylic?
List all other allergies
Eyelash Extensions Consultation Form
Are you currently pregnant? YES NO

Have you ever had eyelash extensions before? YES NO
Are you currently pregnant?
Have you ever had eyelash extensions before?
If yes when was your last procedure
Have you ever had an adverse reaction to eyelash extensions or lash glue?
If yes please describe
Do you have permanent eye makeup?
Do you wear contact lenses?
If yes, will you be wearing them during the eyelash procedure?
Do you currently have any other lash procedures? (Lash lift/tint, lash perm, etc)
If yes please describe
I give permission to the lash technician to perform the following procedures:
Client Signature
Date

MonthDayYear
Date
Date

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EYELASH EXTENSIONS ARE A COSMETIC PROCEDURE THAT INVOLVES THE APPLICATION OF SYNTHETIC OR NATURAL LASHES TO YOUR EXISTING EYELASHES USING A SEMI-PERMANENT ADHESIVE. THIS CONSENT FORM IS INTENDED TO INFORM YOU OF THE RISKS OF THE PROCEDURE AND TO OBTAIN YOUR INFORMED CONSENT FOR THE PROCEDURE.
I understand that although rare, an allergic reaction to the eyelash adhesive can occur. Additionally, I understand that an eye infection, eye irritation, redness, swelling, and damage to natural lashes can occur. I agree that if the adhesive comes into contact with my eye, I will seek medical attention immediately. I understand that the eyelash extension procedure generally takes between 1-2 hours, depending on the number of lashes being applied. During the procedure, I will lie down with my eyes closed while the lashes are applied. I agree to the aftercare procedure recommended by the technician. I understand not adhering to the aftercare procedure can reduce how long the lash extensions last. I understand that results of the procedure may vary and my final result may not be what I initially I give the lash technician permission to photograph my lashes for their own marketing and promotional purposes. I understand that the lash extension procedure isn't permanent, and will require a fill and upkeep as my natural lashes grow out.
I completed the above form to the best of my knowledge. I have had the opportunity to ask any questions and have received satisfactory answers. I understand the risks and potential side effects associated with the lash extension procedure. I understand that the results of the procedure are not guaranteed and may vary from person to person. I consent to the procedure. I will not hold the lash technician, salon, or employees liable for any issues not disclosed at the time of my service or any adverse effects from the lash extension procedure. This agreement remains in effect for this procedure and any follow-up appointments.
Client Signature
Date

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Lash & Blowout Lounge Lash Extensions Consultation Form

Eyelash Extensions Consultation Form