• Lash Extensions & Lash Removal - Client Intake Form

  • Client Information

  • Date of birth*
     - -
  • Format: (000) 000-0000.

  • Emergency Contact

  • Format: (000) 000-0000.

  • Treatment Selection

  • Which service(s) are you receiving today?*

  • Health History

  • Have you ever had a lash extension service before?*
  • Have you ever had a lash extension removal service before?*
  • Have you ever experienced an allergic reaction to lash extensions or a removal service?*
  • Are you currently wearing lash extensions from another salon?*
  • Do you wear contact lenses?*
  • Are you currently pregnant or breastfeeding?*
  • Do you currently have or have a history of any of the following? (Check all that apply):*

  • Medical Information

  • Client Acknowledgements

  • I understand there are risks associated with receiving eyelash extensions and/or an eyelash extension removal. I understand possible side effects include temporary redness, irritation, itching, watery eyes, discomfort, sensitivity, swelling, or in rare cases, infection or blurred vision.

    I understand that allergic reactions may occur even if I have previously received extension services without complications. 

    I understand I have the option to request a patch test before treatment if I have concerns about sensitivity or allergies. 

    I understand that a patch test may reduce, but cannot eliminate, the possibility of an allergic reaction.

    I understand my natural lash length, thickness, strength, and condition may affect my final results, and no specific outcome or longevity can be guaranteed.

    I understand that if my esthetician determines it is not safe to perform this service due to a medical condition, irritation, contraindication, or other safety concern, the service may be postponed or refused.

    I understand contact lenses must be removed before the service begins.

    I understand my eyes must remain closed throughout the service to ensure safety.

    I understand that rubbing, pulling, or picking at my lash extensions may damage my natural lashes.

    I understand that if I experience unusual irritation, swelling, pain, discharge, or vision changes following my appointment, I should contact MaiBeautyyCo immediately and seek medical attention if necessary. Any medical evaluation or treatment will be at my own expense. 

    I agree to notify my esthetician immediately if I experience discomfort during the appointment.

    By initialing below, I acknowledge that I have read, understand, and agree to all of the information provided above regarding the risks, contraindications, possible side effects, aftercare instructions, and expectations associated with the Eyelash Extensions service.

  • Aftercare Instructions

  • I understand and agree to and follow these aftercare instructions to achieve the best possible results.

    • Be gentle with your lashes. Do not rub, pull, or excessively touch them.
    • Avoid sleeping directly on your face whenever possible.
    • Avoid oil-based products around the eye area. 
    • Avoid waterproof mascara
    • Avoid use of mechanical eyelash curlers on lash extensions.
    • Clean my lash extensions regularly using an approved gentle lash cleanser. 
    • Follow proper aftercare to maximize the longevity of your lash extensions.
    • Return every 2-3 weeks for maintenance fills.

    I understand that failure to follow the proper aftercare instructions may shorten the life of my lash extensions.

  • Lash Removal Consent

    (complete only if receiving a removal)

  • I understand that lash extension removal involves the use of professional adhesive remover.

    I understand slight eye watering or sensitivity may occur. 

    I agree not to attempt removing my lash extensions myself, as doing so may result in damage to my natural lashes.

  • Consent & Release

  • I certify that the information I have provided on this form is true, complete, and accurate to the best of my knowledge. I understand that withholding medical information may increase the risk of complications during or after treatment.

    I understand that while every reasonable precaution will be taken to ensure my comfort and safety, no guarantees have been made regarding the results or longevity of this treatment.

    I voluntarily consent to receive the selected Lash Extension and/or Lash Removal service performed by MaiBeautyyCo.

    I release and hold harmless MaiBeautyyCo and its owner, Mariah Cruz, from liability arising from the ordinary and known risks associated with this treatment, except where prohibited by law or in cases of gross negligence or willful misconduct.

    I understand that this consent will remain valid for future Lash Extensions and Lash Removal services unless my medical history changes or this agreement is replaced with an updated version.

    I understand that it is my responsibility to inform MaiBeautyyCo of any changes to my medical history, medications, allergies, pregnancy status, or eye health before future appointments.

    I acknowledge that I have had the opportunity to ask questions regarding this procedure, that my questions have been answered to my satisfaction, and that I fully understand the information provided above.

    By signing below, I acknowledge that I have read and fully understand this consent form, have had the opportunity to ask questions, and voluntarily consent to receive the selected Lash Extension and/or Lash Removal services.

  • Date*
     - -
  • Should be Empty: