Informed Consent: Eyelash 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:
1- 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.
2- I understand that 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.
3- I understand that some irritation, itching or burning may occur on the skin if the bonding agent comes into contact with it.
4- 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.
5- 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 look achieved by replacing the lashes that have fallen out. Most clients require a fill appointment every 2-3 weeks.
6- 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.
7- I understand that it is imperative that I disclose all of the information requested in the Client Profile/Health History.
8- I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications.
9- I understand that additional conditions could occur or be discovered during the procedure which could affect my ability to tolerate the procedure.
10- I consent to “before and after” photographs for the purpose of documentation, potential advertising and promotional purposes.
11- 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.
Please submit your name, email and any questions you may have in the message box.
Lash extension specialist: Ariel Caddow, Shine Beauty Studio
A member of Associated Skin Care Professionals