Eyelash Extensions Consultation/Consent Form | Aesthetics Forms Portal

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Eyelash Extensions Consultation and Consent Form

Client Details

Full Name: *

Date of Birth: *

Contact Number: *

Email: *

Medical Information

Are you currently taking any medications? *

Please list: *

Do you have any allergies? *

Please list: *

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Consultation

Have you had eyelash extensions applied before? *

Why did you have them removed? *

Do you wear glasses or contact lenses? *

Glasses Contact Lenses Neither

Do you have frequent eye irritation, itching, or watery eyes? *

Have you had eye surgery within the last six months? *

Please give details: *

Eyelash extensions require medical tape and adhesives that may contain acrylic or latex.

Are you allergic / have you previously experienced a reaction to latex? *

Are you allergic / have you previously experienced a reaction to acrylic? *

Please check any of the following that apply to you - Relating to the eye:

Eye illness or injury Eye infection Dry eyes Seasonal allergies (e.g. Hay fever) Permanent eye makeup Blepharoplasty Blepharitis (Inflammation of the eyelids) Hypersensitivity to formaldehyde (A by-product released in cyanoacrylate adhesives) Retinoids used to treat acne (e.g. Retin-A or Accutane) Allergies to cyanoacrylate adhesives (i.e. Surgical glue / Nail glue / Crazy glue)

Please check any of the following that apply to you - General:

Hormonal imbalance Recent severe illness or injury Pregnancy or recent childbirth New prescriptions or recently prescribed oral contraceptives Trichotilomania (Hair pulling disorder) Types of medical conditions that may contribute to hair and eyelash loss (e.g. Hyperthyroidism / Alopecia / Lupus) Vitamin and mineral deficiencies that may contribute to hair and eyelash loss (e.g. A / B / F / Iron / Selenium / Zinc) Medications that may contribute to hair or eyelash loss (e.g. Chemotherapeutic agents used in cancer treatment / Anticoagulants / Beta blockers)

ANY ADDITIONAL NOTES/COMMENTS:

Maintenance

No waterproof mascara
No oil based products around the eye area
No water can come in contact with the eye area for 24 hours after the application
No tinting or perming of eyelash extensions
No pulling or rubbing of the eyelash extensions
Should any kind of eye drops be necessary extra care should be taken to prevent moisture from coming into contact with the eyelash extensions

Consent

Consent Statements

Please check each box to show your understanding and agreement:
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 artificial 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 that 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 after-care 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 decrease the time the lashes will last.	.
I understand and consent to having my eyes closed and covered for the duration of approximately 60-120 minute procedure. Times may vary depending on the type and number of eyelashes applied.	.

This agreement will remain in effect for this procedure and all future follow-ups conducted by the certified eyelash extension professional.
I have read and fully understand all information in this agreement. I am over 18 years of age and consent to the agreement and to the eyelash extension application procedure.

By my electronic signature below, I acknowledge that I have read and fully understand this agreement and all the information detailed above. *

Enter Your Full Names Select Font

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Appointment Guidance

If you have tested positive for COVID-19, or have any symptoms of COVID-19 (see below) please do not attend your appointment. Please contact us as soon as you know you will be unable to attend so we can reschedule.

COVID-19 Symptoms:

a high temperature or shivering (chills) – a high temperature means you feel hot to touch on your chest or back (you do not need to measure your temperature)
a new, continuous cough – this means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours
a loss or change to your sense of smell or taste
shortness of breath
feeling tired or exhausted
an aching body
a headache
a sore throat
a blocked or runny nose
loss of appetite
diarrhoea
feeling sick or being sick

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Patch Test Results - Therapist to complete

Date patch test was applied:

Did the client experience a reaction to the patch test?

Please give detail:

Is the treatment going ahead?

Therapist Signature: *

Set a reminder:

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