EYELASH EXTENSIONS CONSULTATION & CONSENT FORM
Please complete this form to help us provide a safe and personalized Eyelash Extensions experience. Your information will remain confidential.
Client Information
Please provide your personal and contact details.
Full Name
*
First Name
Last Name
Email
*
Phone Number
*
Format: (000) 000-0000.
Date
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Month
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Day
Year
HEALTH & SAFETY SCREENING
Please answer the following:
Do you have any known allergies or sensitivities to lash adhesive, tape, gel pads, or eye products?
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No
Yes
Details
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Do you currently have any eye irritation, redness, infection, swelling, stye, dry eye, or recent eye surgery/procedure?
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No
Yes
Details
*
Are you currently wearing eyelash extensions?
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No
Yes
Details
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Have you ever had a reaction to eyelash extensions or lash adhesive before?
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No
Yes
Details
*
Are you pregnant, breastfeeding, or taking any medication or treatment that may affect your eyes, skin, or sensitivity?
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No
Yes
Details
*
CLIENT CONSENT
Consent
*
I confirm that the information above is accurate to the best of my knowledge. I understand that eyelash extension results and retention may vary depending on my natural lashes, eye condition, and aftercare. I understand that irritation or allergic reaction may occur. I agree to inform the provider of any allergy, medication, eye condition, or discomfort before service. I understand that service may be modified, postponed, or declined if it is not safe to proceed.
Client Signature
*
Date Signed (Client)
*
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Month
-
Day
Year
Date
Submit Consultation & Consent
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