Eyelash Extensions Consultation/Consent Form | Beauty Forms Portal

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: *

Do you have any medical conditions? *

Please list: *

Have you recently been unwell? *

Which of the following were you unwell with? *

Please provide more detail: *

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone: *

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:

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:

Possible Risks

Most complications from eyelash extensions result from a skin reaction or allergy to the chemicals used in the glue adhesive.

Symptoms you may experience include:

stinging and burning in the eye and/or on the eyelid
swelling
red or bloodshot eyes
itching
pain
rash

Please tick each statement to show your understanding and agreement. *

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 eyelashes that I will contact the certified eyelash extension professional that performed this procedure and it may be beneficial to have the eyelashes removed. If I am concerned about any of these conditions I will seek medical advice immediately.

Pre-Treatment Guidance

Please, remove all eye makeup by using a gentle, non-oil-containing cleanser. Eye makeup affects the adhesive bond and reduces how long your eyelash can last.
If you’re wearing contact lenses, remove them.
The whole procedure often takes between 90 to 150 minutes for a complete set. Fills take between 30 to 90 minutes. Therefore, please wear clothing that you’ll be comfortable in for the duration of the procedure.
To ensure you are comfortable go to the bathroom before the procedure.
Do not apply face creams or sunblock on the portion of the eyes that is to be treated. Many moisturizers contain oils that prevent adhesives from sticking to the natural eyelash and shorten the lifespan of the eyelash extensions.
Do not wear mascara. Cleaning mascara takes a lot of time and makeup that is left can obstruct the effectiveness of the extension applied.
Do not curl your eyelashes before the appointment. Extensions don’t fit well with wavy eyelashes.
Put your phone on silent mode during the extension application. Communication in the treatment location is not advised because precision is required in the process. You are free to rest or listen to an audio during the extension application.
If you currently have eyelash extensions that were not put on by us, please schedule a removal service on your first visit. It is best to prevent the harm that comes with mixing various adhesives and materials with extensions from other salons.

Maintenance / Aftercare

Avoid getting your eyelashes wet for 48 hours after application - The water will react with the eyelash extension glue and cause a flash cure. The water will cause the eyelash bond to become brittle and break. After the 48 hour period, you’re safe to shower again. Top tip: When showering, don’t position your head in the full strength of water flow. Let the water instead run down your face.
Do not rub or touch your eyes.
Clean with eyelash foam cleanser every 3 days - Using a soft bristle brush and specialist eyelash extension cleaning foam, clean approximately every 3 days. Getting into this habit removes traces of natural oils, dust and make-up. This prevents any build-ups causing pressure on your lashes and breaking down the bond. Ultimately, you need to clean clean clean to avoid premature eyelash shedding.
Brush through your eyelash tips in the morning.
Do not apply mascara - The product gets caught between the eyelashes and builds up. This, in turn, becomes much harder to clean and may lead to premature eyelash loss and affects your eye health.
Do not use oil based products around or on the eyes.
Do not sleep on your face.
Stay on top of your infills (recommended every 2 - 3 weeks).

Please tick the box to confirm: *

I have read and understood the aftercare advice provided to me on this form.

Consent

I accept that any treatment I am going to receive is at my own risk.

I certify that I have read, fully understood, and completed this form to the best of my knowledge.

I understand that failure to disclose information requested above may result in adverse side effect(s), unknown because of this to which I accept full liability/responsibility.

The treatment(s) and possible side effect(s) have been fully explained to me.

I accept full responsibility for the treatment given and complications which may arise or result during or following any procedure that is performed at my request.

I accept that if I am not satisfied with the treatment I will inform the therapist and/or request to speak to the manager during, or immediately following, the treatment.

I fully understand the above and consent to the Eyelash Extensions treatment(s) to be carried out.

Client Signature: *

Tap or click on the signature above to sign

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: