Consent Form

Name

First Name Last Name

Date of Birth

Email

example@example.com

Instagram Handle

@example

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Referred by

Phone Number

Area Code Phone Number

Previous Treatments

eyelash extensions lash lift eyelash extension removal permanent makeup

Conditions

sensitive eyes watery eyes itchy eyes glaucoma conjuctivius stye eye surgery trichotillomania blepharitis

Allergies

cyanoacrylate nail adhesives acrylic nails latex

I understand that this procedure requires single synthetic eyelashes to be adhered to my own natural eyelashes.

YES

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.

YES

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.

YES

I agree to disclose any allergies that I may have to latex, surgical tapes, cyanoacrylates, etc.

YES I have an allergy to one of the above

Due to the tedious and extensive nature of eyelash extension application, I understand that a refund will NOT be provided after application. However, if necessary a complementary removal will be provided once the allergic reaction subsides.

YES

I understand that I am required to follow the eyelash extension care sheet (attached here to) in order to maintain the life of the extensions.

YES

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

YES

I understand that there are many variables including natural lash growth cycle, use of cosmetics and skin careproducts, sleeping habits and hygiene that will influence how long my Eyelash Extensions remain in place.

YES

I understand that if Eyelash Extensions are not properly cared for and cleaned on a daily basis, that oil andmakeup can build up causing sensitivity and possible irritation or infection. It is mandatory to arrive with NO mascara or liner for touchups.

YES

I consent to “before and after” photographs for the purpose of documentation, potential advertising and promotional purposes.

YES

I understand that there is a 48 hour cancellation policy. Cancellations & rescheduling with less than 48 hours notice will be charged a 100% cancellation fee. No shows will be banned from booking.

YES

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 eyelash extension procedure we have discussed, and will holdhim/her and his/her staff harmless and nameless from any liability that may result from this treatment. I haveaccurately 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.

YES

I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunityfor 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, whichmay be affected by the treatment performed today.

YES

Date

Client Name (Signature):

Clear