Eyelash Extensions Consent Form

I have agreed to have eyelash extensions applied and/or removed from my eyelashes. Before my qualified professional eyelash technician can perform this procedure, I understand I must complete this agreement and provide my consent by signing and dating this two page consent form. For each condition and adverse reaction, write YES if you have the condition and NO if you do not have the condition.

We want to make sure that you love your lashes! Therefore, you have up to 4 days to contact Lash Lab if you are unhappy with your lash extensions.

I understand that if I am late to my appointment or leave before my appointment time is over then I can not come back and receive any touch ups or services free of charge.

I understand and agree to the cancellation policy at Lash Lab. If I cannot make it to my appointment, I must cancel 24 hours PRIOR to my scheduled appointment. Any appointments cancelled within 24 hours of the scheduled time will be charged 50% of the service. Not showing up to any appointment will also incur a 50% fee.

Initial here

	Condition	Adverse Reactions
1.	Allergic to adhesives (glues, tapes, band aids, etc.)	Eyelash extension uses adhesive tapes, glue and gel pads that may cause an allergic reaction.
2.	Chemotherapy Treatments within the last 6 months	Medication for chemotherapy may cause a reaction to the materials used for eyelash extensions.
3.	Thyroid Medications	Eyelash extensions will not last due to the medication system.
4.	Lasik Surgery less than 4 months (must wait 4 weeks post-op for medical consent)	Eyes may have sensitivity to eyelash extensions and products used for prepping the eye area (glues, gel pads).
5.	Blephoroplasty (must wait 6 months post-op for medical consent)	Eyes may have sensitivity to eyelash extensions and products used for prepping the eye area (glues, gel pads).
6.	Contact Lenses	Glue used to apply the eyelash extensions may get underneath the contact lenses and cause corneal abrasion or scratching. Contact lenses must be removed prior to eyelash extension procedures.
7.	Extremely oily skin and hair	Natural oils will break down the adhesives used to bond the eyelash extensions causing the eyelash extensions to fall out.

I have this condition/I do not have this condition

1. yes/no

2. yes/no

3. yes/no

4. yes/no

5. yes/no

6. yes/no

7. yes/no

Name

First NameLast Name

Signature

Date

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Phone Number

Area CodePhone Number