Eyelash Extensions
Consultation & Consent Form
Name*
First Name Last Name
Phone Number
Area Code Phone Number
Referred by: blanks
Client Health History
Please list any allergies you have (including cosmetics/ingredients): blanks
Are you allergic to acrylate/cyanocarylate (bonding agent)?*
Yes No Don’t Know
Have you ever had a reaction to adhesive tape, topical creams, nail adhesives, or other topical products?*
Yes No
Do you have an eye disease, condition or injury that has affected your hair/lash growth or loss?*
Yes No
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?*
Alopecia Asthm Back pain or back injury Bell’s Palsy Blepharitis Claustrophobia Cold Sores Conjunctivitis (pink eye) Diabetes Dry Eye Symptoms Eye Sites or Sores Herpes of the Eye Intense Stress Leamy eye Light Sensitivity Migraines Ocular Rosacea Rosacea Sensitive Eyes Stroke/TIA Thyroid Disease Trichotillomania Recent Eye Surgery Current Eye Irritation None of the above
Any other health conditions not listed: blanks
Are you pregnant or nursing?*
Yes No
Do you wear contacts?*
Yes No
Do you wear glasses?*
Yes No
Have you ever had eyelash extensions?*
Yes No
Have you ever had eyelash extensions removed?*
Yes No
Do you use Retin-A or Accutane?*
Yes No
Do you go tanning (in salon, outdoor, or spray tan)?*
Yes No
Have you had facial treatments?*
Yes No
Have you ever had Botox, Juvederm or any other injectables?*
Yes No
Have you ever used Latisse or any other lash growing product?*
Yes No
Which side do you sleep on?*
Right Left Stomach Back
How fast do you feel your hair grows?*
Fast Slow Normal Rate
Is there anything else we should know? blanks
Post Treatment and Homecare
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 (refills) to your own eyelashes as your eyelash growth cycle regenerated new 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
- Avoid using oil-based skincare and makeup products around the eye, including mascara and makeup remover.
- Avoid water mascara. If you can, it is between not to use any mascara at all. You may find you don't even need it!
- Avoid running water over your face. Moisture will break down the bond of glue.
- 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. One of the benefits of lash extensions is the ability to add curl to your lashes. If yo would like more curl, please speak to your technician.
- 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 your lashes, and do not attempt to remove them yourself. If you would like them removed, please contact your technician.
If you experience and pain, redness or irritation; contact your technican 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 if the bonding agent comes into contact with my eye, my eye will be flushed with water and I will be assisted in seeking medical attention immediately.*
Initial
I understand tat 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 while every attempt will be make to provide me with the length and fullness I have chosen, my final result may not be what I initially envisioned.*
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 content 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 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, Brianna Savoy, 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.
Signature*
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Eyelash Extensions

Client Health History

Post Treatment and Homecare

Informed Consent