• Consent and Intake Form

  • Format: (000) 000-0000.

  • Consent

  • I   *   *   agree to have eyelash extensions applied to my natural eyelashes and/or removed and retouched. By signing this agreement, I consent to the placement and/or removal of the eyelash extensions by the certified eyelash extension professional.

       *   I understand that in rare occasions there are risks associated with having artifi cial eyelashes and eyelash extensions applied to or removed from my natural eyelashes. I further understand that in rare cases as part of the procedure eye irritation and discomfort could occur. I agree that if I experience any of these conditions with my lashes, I will contact the certified eyelash extension professional that performed this procedure, and it may be beneficial to have the eyelashes removed.

       *   I understand and agree to the aftercare instructions provided by the certified eyelash extension professional for the use and care of my eyelash extensions. I realize and accept the consequences of failure to adhere to these instructions may cause the eyelash extensions to fall out, and/or impact the time that the lashes will last.

       *   I understand and consent to having my eyes closed and covered for the duration of procedures for 60 - 180+ minutes or more. Times vary depending on the type and number of eyelashes applied.

       *   I agree to inform the eyelash extension professional of the following at time of service:
    • Current use of contact lenses, which I may be asked to remove during the procedure.
    • Current use of anything such as oil-containing sunscreen or moisturizers around the eyes.

       *   This agreement will remain in effect for this procedure and all future follow–ups conducted by the certified eyelash extension professional. I read English and understand that this consent agreement is legal and binding. I have read and fully understand all information in this agreement.

       *   I am 18 years of age or older and consent to the agreement and to the eyelash extension application procedure.

  • Clear

  • Intake

  • Have you had eyelash extensions before?*
  • Do you wear glasses?*
  • Do you wear contacts?*
  • Do you use any eye drops of any kind? (Over-the-counter or prescription)?*
  • Relating to the eyes - check all that apply:
  • Are you currently pregnant?*
  • Have you had any surgeries within the last 6 months?*
  • Do you deal with any of the following? Please check all that apply.

  • The information I have provided is, to the best of my knowledge correct and I agree to update my information should any changes occur.

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