Consent-Eyelash

What side do you predominately sleep on? *

Right

Left

I Don't Know

What desired look do you plan to achieve? *

More Natural

More Striking

How did you hear about us? (if you were referred, please list the client's name below so that I may thank them for their trust)

Please initial each statement: I understand that there are risks associated with the application and /or removal of artificial eyelashes. These risks include, but are not limited to: eye irritation, eye pain, discomfort, and in rare cases, blindness. *

Do you habitually rub, pull, or pick your natural eyelashes? *

Yes

No

Address *

Do you have or are you being treated for any eye illness or injury? *

Yes

No

I understand that the procedure requires that I lay still for up to 1 hour or longer with my eyes shut. *

Please indicate if you have worn any of the following within the past 60 days:

Individual Eyelash Extensions

Eyelash Strips

Flare

Other

Name: *

I acknowledge that I should not rub my eyes or pull my lashes after eyelash extensions have been applied. *

I understand that there are many variables, including technician expertise, hair growth cycle, use of cosmetics and skin care products and the overall care given, that will influence how long my eyelash extensions remain in place. *

Phone *

Today's Date *

By checking this box, I consent to the eyelash extension procedure. *

Agree

Are you able to keep your eyes closed and lie still for 1 hour or more? *

Yes

No

Which of the following reasons are you having your lash extensions applied for? *

Daily Wear

Special Occasion

Both

As part of this procedure, I understand that a certain amount of eyelash adhesive will be used to apply each extension to my existing lashes. Although the Certified Eyelash Extensionist may apply and/or remove the eyelash extension properly, I understand that there is a possibility that the adhesive may become dislodged during and or after the procedure, which my irritate my eyes or require further follow-up care. *

Please list any eye drops or eye medications that you are using currently: (if none, please skip).

I understand that I should not get my eyelash extensions wet within 24 hours after application. *

Do you wear contacts? *

Yes

No

I have no known medical condition that might be aggravated by the procedure. *

Will this be the first time you have had eyelash extensions applied? *

Yes

No

I understand that using mascara on a regular basis can shorten the length of time my extensions remain in place. I have also been advised not to use waterproof mascara on my eyelash extensions. *

Email: *