Name *

First Name

Last Name

Phone *

(###)

###

####

Date *

MM

DD

YYYY

Birthday *

MM

DD

YYYY

Have you had eyelash extensions before? *

Yes

No

Have you ever experienced allergic reaction to eyelash extensions? *

Yes

No

Do you have sensitive eyes? *

Yes

No

Disclaimer & Consent *

Allergic reactions to eyelash extensions are caused by an allergy to the cyanoacrylate base (bonding agent) that is basically in every eyelash extension adhesive. If you develop an allergy to the adhesive you may experience swelling. itchy eyes, and/or redness. Allergic reactions to the adhesive are rare. I ask that you do not get eyelash extensions if you have experienced allergies to the lash adhesive ever in the past or if you have very sensitive eyes.

I certify that I have read all the information above

I fully understand the risk associated with eyelash extensions

I understand that I am fully responsible for the maintenance of my eyelash extensions

I understand that I must follow all of the eyelash extensions aftercare instructions

I understand it is my responsibility to keep my eyes closed and stay still during the entire application process I understand that I am required to follow the eyelash extension aftercare instructions in order to maintain the health of my natural lashes and the extensions

I understand that the fumes from the adhesive may cause my eyes to water during the application process

I understand that some of the risks involved with this procedure may be, but are not limited to eye redness, swelling, and/or irritation

I understand and acknowledge that this consent & release discharges me, (your name here), from any liability or claim that I may have with respect to any bodily injury, personal injury, property damage or any other claim that may result from the services provided