LASH EXTENSION CONSENT FORM

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Name* This field is required.
First Name
Last Name
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Date of Birth* This field is required.
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Email* This field is required.
example@example.com
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Instagram Handle* This field is required.
@example
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
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Angola
Anguilla
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The Bahamas
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Mali
Malta
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Martinique
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Mayotte
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Moldova
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Mongolia
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Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
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Palau
Palestine
Panama
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Paraguay
Peru
Philippines
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Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
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Samoa
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Senegal
Serbia
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South Ossetia
South Sudan
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eSwatini
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Taiwan
Tajikistan
Tanzania
Thailand
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Tokelau
Tonga
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Tristan da Cunha
Tunisia
Turkey
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Uruguay
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Vanuatu
Vatican City
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Isle of Man
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Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Referred byyour bestie gets half off her fill for your refferal 🎉
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Phone Number* This field is required.
Area Code
Phone Number
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Have you had your lashes done in the past? Was it a good or bad experience?
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How do you sleep?* This field is required.
Right Side
Left Side
Back
Stomach
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What do you expect from your set?* This field is required.
fullness
length
full on glam
natural yet noticeable
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Previous Treatments* This field is required.
eyelash extensions
lash lift
eyelash extension removal
permanent makeup
N/A
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Conditions* This field is required.
sensitive eyes
watery eyes
itchy eyes
glaucoma
conjuctivius
stye
eye surgery
trichotillomania (hair pulling)
blepharitis
none applicable
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Allergies* This field is required.
cyanoacrylate
nail adhesives
acrylic nails
latex
none applicable
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I understand that this procedure requires single synthetic eyelashes to be adhered to my own natural eyelashes.* This field is required.
YES
15
I understand that it is my responsibility to keep my eyes closed and be still during the entire procedure, until my eyelash technician addresses me to open my eyes.* This field is required.
YES
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I understand that eyelash extension services have some inherent risk of irritation to the orbital eye area, 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.* This field is required.
YES
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I agree to disclose any allergies that I may have to latex, surgical tapes, cyanoacrylates, etc.* This field is required.
YES
I have an allergy to one of the above
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Due to the tedious and extensive nature of eyelash extension application, I understand that a refund will NOT be provided after application.* This field is required.
YES
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I understand that I am required to follow the eyelash extension care sheet in order to maintain the life of the extensions.* This field is required.
YES
20
I acknowledge that I should not pull on my lashes or pluck them or attempt to remove them myself after they have been applied as this will cause lash loss/damage* This field is required.
YES
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I understand that there are many variables including the natural lash growth cycle, use of cosmetics and skin care products, sleeping habits, and hygiene that will influence how long my Eyelash Extensions remain in place.* This field is required.
YES
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I understand that if Eyelash Extensions are not properly cared for and cleaned daily, oil and makeup can build up causing sensitivity and possible irritation or infection. It is mandatory to arrive with NO mascara or liner for touchups.* This field is required.
YES
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I understand 2-3 lashes will fall daily up which is why I need fill ins every 2-3 weeks to maintain fullness.* This field is required.
YES
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I understand having shorter thinner lashes may result in a shorter life span in my lash set. Incorporating a lash serum will help with new growth & length and better longevity & has been offered to me.* This field is required.
YES
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I consent to “before and after” photographs for the purpose of documentation, potential advertising and promotional purposes.* This field is required.
YES
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I understand that there is a late cancellation policy. Same day cancelations your deposit will be one time be applied to your future appointment. If that appointment is missed the deposit is forfeit. No-shows forfeit your deposit and will require full payment for future bookings.* This field is required.
YES
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I understand that if I have any concerns, I will address them with my lash extension specialist. I permit my lash extension specialist to perform the eyelash 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 all 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 that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures.* This field is required.
YES
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I certify that I have read, and fully understand the above paragraphs 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 the lash extension specialist, whose signature appears below, or the salon in which the service was performed, responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today.* This field is required.
YES
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Any Questions feel free to let me know before we meet
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Date* This field is required.
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Client Name (Signature): * This field is required.
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