Client Patch Test Consultation Form

Lash Extensions Patch Test Consultation Form - Part 1

This form is required if a patch test is being carried out by Lashour, for a client who has never had lash extensions before. This form must be complete prior to the appointment.
Name*

First NameLast Name
Email*
example@example.com
DOB*
Where did you hear about Lashour?*
Phone Number*

Area CodePhone Number
Treatment Type*

Client Medical Details (all information will remain confidential)*

Rows	Yes	No
Allergy to latex, plasters, collagen, fish, acrylic nails?
Asthma?
Hayfever?
Claustrophobia?
Light Sensitive?
Smoker?
Eye Disorders?
Contact Lens (must be removed for treatment)
Taking HRT or steroids, thyroid medication?
Pregnant?
Oily Skin & Hair?
Chemotherapy within the last 6 months?
Sunburn?
Undiagnosed Lumps/Bumps?
Psoriasis in the area?
Blepharitis (inflammation of the eyelid)
Eczema
Any recent chemical treatments?
Other known allergies? (If yes please state in text box below table)

Please use this text box for other allergies or additional information you believe would be important
A patch test for lash extensions consists of a couple lashes being attached to a couple of your natural lashes. All products used at your actual appointment will be used during your patch test to ensure you're not allergic to any products used.

You must not get your lashes wet for 48 hours to complete the patch test. If your eyes become itchy, swollen, red and sore please notify me straight away as this could mean you have had a reaction to one of the products. If this is the case, the treatment cannot go ahead.

Please bear in mind this does not give a clear indication of whether a reaction will occur or not. This is because of 2 reasons:

1. A patch test does not give full exposure in the same way as the full treatment.
2. Allergies are cumulative, meaning they build up over time.

It is more likely for allergies, sensitivities, and reactions to occur after you have been having these treatments for 6 months or more. This is because sensitivity will build up each time you are exposed to these solutions.

This means that a patch test will not accurately test for allergies and a reaction could still occur even if the patch test results are negative.
Once you have read and understood the above and given all the necessary information, please read and tick the following statements to confirm you understand:
I have read and understood the information regarding patch testing.I have been offered the option of a patch test. I will be going ahead and having a patch test before the treatment appointment.I accept there may be a risk of an adverse reaction to this treatment including the possibility of swelling, irritation and rednessI understand an adverse reaction can happen at any time and not necessarily after the initial treatment.I understand that if any of these reactions occur I should contact my technician immediately. If symptoms persist, I must seek medical attention.I understand that in the case of a reaction I will not hold my technician responsible in any way. This includes any of the reactions specified above and/or any other reactions I may have.
CONSENT:

I can confirm that I have completed this form to the best of my knowledge and understand that if there are any changes to my medical or personal details I will make my technician aware before any treatment/s are carried out.
(Client Signature)*

Clear

Lash Extensions Patch Test Consultation Form - Part 2

to be completed after 48 hours of your patch test.
YesNo
If No, Please state why
Important Client After Care Advice

I agree to follow the aftercare advice given by given by my therapist at the end of my appointment and understand that failure to do so can cause premature loss of the lashes and as such my therapist will not be held responsible.

If you have any problems with your eyelash extensions, then please let your therapist know immediately and within any designated time offered by your therapist.

If any client experiences a problem with their lashes, then your therapist will do their best to work with that client to rectify the problem. However, please note that the products used an all clients are tried and tested and as such, they do work, with satisfied clients returning week after week with healthy natural lases and well-maintained extensions. In the rare event of a client experiencing any problems, it is usually as a result of improper aftercare, or that they may not be a suitable candidate for lash extensions. Although eyelash extensions are a fantastic beauty treatment, there may be times when they are not suitable for everyone.

Refunds are not offered on eyelash extension treatments.

Pleae return for your infill within 2-3 weeks, after which you will be charged additionally for the extra work needed and you may need a full set.

Cancellation Policy

Please make yourself familiar with the cancellation policy set by your therapist. Last minute cancellations/rescheduled appointments and ‘no-shows’ will result in your deposit being lost. When a therapist does not work, they do not earn, therefore please respect the policies put in place to protect your therapist.

Please be prepared and on time, as you have a designated slot. Your appointment is more than enough time to ensure you receive your treatment. Lateness will eat into your appointment time, but you will still be charged full price.
(Client Signature)*

Clear
Should be Empty:

Lash Extensions Patch Test Consultation Form - Part 1

Once you have read and understood the above and given all the necessary information, please read and tick the following statements to confirm you understand:

CONSENT:

Lash Extensions Patch Test Consultation Form - Part 2