How were you referred to us?
Surgery less than 4 months ago (must wait 4 weeks post-op exam for medical consent)
Blepharoplasty (must wait 6 months post-op for medical consent)
Are you allergic to Acrylate/Cyanoacrylate?
Do you have any eye disease, condition, or injury that has affected you hair/lash growth or loss?
Are you taking any Thyroid medications?
Have you ever had a reaction to adhesive tape, topical creams, nail adhesives, or other topical products?
Chemptherapy treatments within the last 6 months?
Do you have extremely oily skin or hair?
Do you have any of the following medical conditions? (Check all that apply)
These questions are relevant to hair growth, and overall health. Please answer as truthfully as possible.
Are you pregnant or nursing?
Do you wear contacts?
Do you wear glasses?
Do you use RetinA or Accutane?
Have you had a facial treatment in the last month?
Have you ever had Botox, Juvederm, or any other injectables?
Do you habitually rub, pull, or pick at your lashes for any reason?
Are you having lash extensions applied for:
Have you ever used long lasting or waterproof cosmetics?
Have you ever had eyelash extensions?
Have you ever had eyelash extensions removed?
Do you curl, perm, or tint your lashes?
Do you go tanning? (in salon, outdoor, or spray tan)
Have you ever used Latisse or any other lash growing products?
Which side do you most often sleep on?
How fast do you feel your hair grows?
  • I understand that the eyelash extensions will be applied to the natural lash as determined by the technician so as not to create excessive weight on the natural eyelash thereby preserving the health, growth, and natural look the the client's eyelashes.
  • I understand as part of the procedure eye irritation, eye pain, eye itching, discomfort, and in rare cases eye infection may occur.
  • I understand and agree that if I experience any of these issues with my lashes that I will contact my technician and have the eyelashes removed immediately and consult a physician at my expense.
  • I understand that even though the technician may apply and remove the eyelashes properly, the adhesive materials may become dislodged during or after the procedure, which may irritate my eyes or require follow up care.
  • I understand and agree to follow the aftercare instructions provided by my technician. Failure to follow the aftercare instructions can cause the eyelash extension to fall out.
  •  I understand that in order to have the eyelash extension applied to my eyelashes I will need to keep my eyes closed for the duration of 60-100 minutes during the procedure. I also understand that I will need to be lying in a reclined position. Any medical conditions that might be aggravated by lying still for a prolonged period of time may mean that I will not be able to have the procedure performed on my eyes.
  • I understand that After Photos will be taken of my lashes and may be posted on the studio website and/or the studio's social media.
  • I understand and agree that if I have chosen not to remove my contacts I am fully responsible for any negative consequences caused by this decision
  • This agreement will remain in effect for the procedure and all future procedures conducted by my technician for one year from the date of this signed form. 
  • I understand that this agreement is binding and that I have read and fully understand all information listed above.
  • I represent that I am over the age of 18. If below 18 years of age a parent or guardian must also sign this form. 
  • I understand that if I am a model, my lashes may not come out perfect and that these are students who are still in training. I also understand the time commitment because of this.

Thanks for submitting!

For office use only
Eye Shape
Eyelash Extension Type