Informed Consent: Lash Extensions
Although every precaution will be taken to ensure your safety and wellbeing 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.
I understand that the lash extension services have some inherent risk of irritation to the orbital eye area, 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.
I understand that some irritations, itching or burning may occur on the skin if the bonding agent comes into
contact with it.
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.
I understand that this is a semi-permanent procedure, as my natural lashes will continue to grow and fall out
normally, making touch-up or “fill” appointments necessary to maintain the original looks achieved by replacing
the lashes that have fallen out. Most clients require a fill appointment every 2-3 weeks.
I understand that while every attempt will be made to provide me with the length and fullness I have chosen, my
final result may not be what I initially envisioned.
I understand that it is imperative that I disclose all of the information requested in the Client Health History.
I have cited all conditions and circumstances regarding my health history, medications being taken, and any past
reactions to products or medications.
I understand that additional conditions could occur or be discovered during the procedure which could affect my
ability to tolerate the procedure.
I consent to “before and after” photographs for the purpose of documentation, potential advertising and promo-
tional purpose.
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 all 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 that this constitutes full
disclosure, and that it 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, whose
signature appears below, 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 today.
Client Name (Printed)
Client Name (Signature)
Date:
Lash extension specialist:
For Professional Use Only
Curl Used:
Thickness Used:
Placement of Extensions:
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