Lashes By LJ Client Consent & Consultation Form

Client Consent and Consultation form

Please read carefully and sign to give consent to work under these conditions. Reach out for any questions or concerns.
Name*

First NameLast Name
Email*
Contact Number*
Referred by: First Name Last Name
Client Health History
Please list any allergies you have (including cosmetics and/or ingredients): blanks
Are you allergic to acrylate/cyanocarylate (bonding agent)?*

YesNoDon’t Know
Have you ever had a reaction to adhesive tape, topical creams, nail adhesives, or other topical products?*

YesNo
Do you have an eye disease, condition or injury that has affected your hair/lash growth or loss?*

YesNo
Please list all current medications you are taking (including over-the-counter herbs, vitamins and supplements): blanks
Have you ever had any of these conditions?*

AlopeciaAsthmaBack pain or back injuryBell’s PalsyBlepharitisClaustrophobiaCold SoresConjunctivitis (pink eye)DiabetesDry Eye SymptomsEye Sites or SoresHerpes of the EyeIntense StressLeamy eyeLight SensitivityMigrainesOcular RosaceaRosaceaSensitive EyesStroke/TIAThyroid DiseaseTrichotillomaniaRecent Eye SurgeryCurrent Eye IrritationNone of the above
Any other health conditions not listed: blanks
Are you pregnant or nursing?*

YesNo
Do you wear contacts?*

YesNo
Do you wear glasses?*

YesNo
Have you ever had eyelash extensions?*

YesNo
Have you ever had eyelash extensions removed?*

YesNo
Do you use Retin-A or Accutane?*

YesNo
Do you go tanning (in salon, outdoor, or spray tan)?*

YesNo
Have you had facial treatments?*

YesNo
Have you ever had Botox, Juvederm or any other injectables?*

YesNo
Have you ever used Latisse or any other lash growing product?*

YesNo
Which side do you sleep on?*

RightLeftStomachBack
How fast do you feel your hair grows?*

FastSlowNormal Rate
Is there anything else we should know? blanks
Post Treatment and Home-care
Your lash extensions are attached to your own individual eyelashes, and will shed as your natural lashes shed. Maintaining your lash extensions will require regular visits to attach new extensions (fills) to your outgrown lashes and regenrated lashes.

With a few simple care instructions you will be on your way to enjoying your luscious long lashes. To increase the longevity of your lashes, it is advised to avoid moisture and touching as much as possible.

Before your appointment:
- If you use waterproof mascara, avoid using it 2-3 days before your first appointment. The film it leaves on your lashes may prevent the extensions from adhering correctly.
- Arrive to your appointment with dry, clean lashes and makeup-free eyes.
- Remove contact lenses before your appointment.
During the initial 24-48 hours after your appointment:

Do not get your lashes wet for 24 hours after the lash extensions are applied. It will affect the efficacy of the glue.
- Avoid steam from showers, facials, saunas and swimming pools.
- Avoid getting moisture around the eye area when washing face, showering, etc.
- Avoid tanning beds for 48 hours after application.
- Avoid chemical peels, waxing or laser treatments around the eyes.
General guidelines to extend the life of your lashes
- Cleanse lash extensions daily.
- Avoid using oil-based skincare and makeup products around the eye, including mascara and makeup remover.
- Avoid any mascara. You will find that you don't even need it!
- Avoid rubbing your eyes or lashes, especially when washing your face. It is recommended to clean around the eye area with a washcloth or cotton swab (Q-tip).
- Avoid using an eyelash curler.
- If you can, sleep on your back to avoid the risk of lashes rubbing against your pillow.
- Gently brush your lashes with a mascara wand to groom them. The best time to do this is after showering, as they will be softer and less likely to damage.
- Avoid pulling or touching your lashes, and do not attempt to remove them yourself. If you would like them removed, please contact your technician.
If you experience any pain, redness or irritation; contact your technician immediately.
Informed Consent

Although every precaution will be taken to ensure your safety and well-being before, during and after your lash extension application, please be aware of the following information and possible risks. Please Initial:
I understand that a full set of lash extensions can make the appearance of my own lashes about 30-50% thicker, and make my lashes appear 20-50% longer.*
Initial
I understand that the lash extension services have some inherent risk of irritation to the orbital eye areas, including the eye itself, and could result in stinging and burning, blurry vision and potential blindness should the adhesive enter the eye or should an allergic reaction occur. *
Initial
I understand that some irritation, itching or burning may occur on the skin if the bonding agent becomes into contact with it.*
Initial
I understand that this is a semi-permanent procedure, as my natural lashes will continue to grow and fall out normally, making touch-up or “refill” appointments necessary to maintain the original look achieved by replacing the lashes that have fallen out. Most clients require a fill appointment every 2-3 weeks.*
Initial
I understand that I am responsible for maintaining healthy lash hygiene in order to come with the best retention between 40-50%.*
Initial
I understand that while every attempt will be made to provide me with the length and fullness I have chosen, my final result may not be what I initially envisioned due to different eye shapes.*
Initial
I understand that it is imperative that I disclose all of the information requested in the client profile/health history.*
Initial
I have cited all conditions and circumstanced regarding my health history, medications being taken, and any past reactions to products or medications.*
Initial
I understand that additional conditions could occur to be discovered during the procedure which could affect my ability to tolerate the procedure.*
Initial
I consent to “before and after” photographs for the purpose of documentation, potential advertising and promotional purposes.
Initial
I understand that if I have any concerns, I will address these with my lash extension specialist. I give permission to my lash extension specialist to perform the lash extension procedure we have discussed, and will hold him/her and his/her staff harmless and nameless from any liability that may result from this treatment. I have accurately answered the questions above, including any known allergies, prescription drugs or products I am currently ingesting or using topically. I understand my lash extension specialist will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult the lash extension specialist immediately. I agree this constitutes full disclosure, and that is supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and policies from lashesbyLJ.com/policy and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold Lashes By LJ and/or the lash extension specialist, Louajee Churchon, responsible for any of the conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed.
Date*

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Date
Signature*

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Client Consent and Consultation form

Client Health History

Post Treatment and Home-care

Informed Consent