Consent Form

First name

Last name

Email

Phone Number

Date of Birth

Month

Day

Year

Is this your first time getting lash extensions?

Yes

No

Do you wear contacts?

Yes

No

Do you often pick, pull or rub on your lashes for any reason?

Yes

No

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

Yes

No

If yes, please list the illness or any eye drop you’re using

Are you able to lay down more than 2 hours?

Yes

No

Are you pregnant?

Yes

No

Are you taking any vitamins or serums for hair growth?

Yes

No

Do you have sensitive eyes?

Yes

No

Are you allergic to adhesives (glues, tapes, band-aids, etc.)? This service may use adhesive tapes, glues, and gel pads that could cause an allergic reaction. We use medical-grade, formaldehyde-free glue, but allergies may still occur.

Yes

No

Have you had chemotherapy in the past 6 months? Chemo meds may react with materials used in this service. If your lashes are just starting to grow back, they may be weak—we recommend waiting until they’re strong enough.

Yes

No

Are you currently taking Thyroid Medications? Thyroid medications or Thyroid Conditions may not last long due to either of these.

Yes

No

Initials:

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I understand that eyelash extensions require ongoing maintenance, with refills recommended approximately every 2–4 weeks. I acknowledge that if I exceed this timeframe, a full set may be required.

I will seek medical care at my own expense and contact my lash artist immediately if any allergic or adverse reaction occurs. All of my questions have been answered, and I understand the procedure and its risks.

I understand there are risks associated with having semi-permanent eyelash extensions applied to and/or removed from my natural eyelashes.

I understand that there are risks associated with the application and/or removal of semi-permanent eyelash extensions from my natural lashes.

I understand that the eyelash extensions will be applied to the eyelash extensions as determined by the technician so as not to create excessive weight on the natural eyelash thereby preserving the health, growth and natural look of the clients eyelashes.

I understand and agree to follow the aftercare instructions provided by my technician. I acknowledge that failure to do so may cause the eyelash extensions to fall out prematurely.

I accept full responsibility for any reaction that may occur. I understand the possibility of an allergic reaction and agree not to hold my lash artist liable. I acknowledge that no refund will be issued in the event of a reaction, as the service has been completed.

I understand and agree that all sales are final and no refunds will be issued.

I understand that lash extensions are not permanent.

I understand all cancelation policies.

You will not be charged if you cancel at least 48 hours before your appointment. Late cancellations (under 48 hours) will be charged 50% of the service cost. No-shows or same-day cancellations will be charged 100%. No exceptions. Failure to pay cancellation fees will result in a ban from future bookings.

By signing this form, I release Irma Gavidia from any liability. This agreement applies to this treatment and all future treatments by my eyelash specialist for one year from the date of signing.

I understand that this agreement is binding, and I have read and fully understand all the information above.

I represent that I am over 18 years of age. If under 18, a parent or guardian must also sign this form.

Signature

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Parent or guardian signature if applicable:

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