Eyelash Extension Patch Test Waiver Form
Please complete this form to acknowledge your understanding and consent for the eyelash extension patch test.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Patch Test
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you ever had a reaction to eyelash extensions or adhesives before?
*
Yes
No
Emergency Contact Name
Emergency Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Additional Comments (optional)
Signature
*
Submit
Submit
Should be Empty: