Request edit access
Lash Extensions Consent Form
Please complete and submit.
Sign in to Google to save your progress. Learn more
First and last name: *
Date of procedure: *
Date of birth: *
Is this your first time receiving lash extensions? *
Please provide a description of your last procedure. List any helpful details that will allow us to customize your experience. Example: preferences, expectations, etc.
Do you have a tendency to pick or pull your natural lashes? *
Have you used a lash growth serum in the last 6 months? *
If yes, please list serum:
How often do you wear strip lashes? *
I understand that there are risks associated with having artificial eyelashes applied to and/or removed from my natural lashes. *
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 of the client's natural lashes. *
I understand that as part of the procedure eye irritation, pain, 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 I will contact my technician and have the eyelash extensions removed immediately and consult a physician at my own expense. *
I understand that even though the technician may apply and remove the eyelash extensions properly, that adhesive material may become dislodged during or after the procedure, which may irritate my eyes or require further follow up care. *
I understand and agree to follow the aftercare instructions provided by my technician. Failure to follow the aftercare instructions may cause the eyelash extensions to fall out. *
I understand that in order to have the eyelash extensions applied to my eyelashes I will need to keep my eyes closed for a duration of 45-180 minutes during the procedure. I also understand that I will need to be lying down. 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. *
This agreement will remain in effect for this procedure and all future procedures conducted by my technician or any other technician conducting business at Vine Lash & Beauty Co. I understand that this agreement is binding and that I have read and fully understand all information above. I represent that I am over the age of 18 years old. If below 18 years of age a parent or guardian must also sign this form. *
If below the age of 18 years old, please have your parent or guardian sign here by typing their name below.
I release my technician and Vine Lash & Beauty Co. from all liabilities associated with this procedure. There are no refunds, and there are no guarantees for the bonding time length of the eyelash extensions. The company or salon is not responsible for any technician errors. I understand that I have been advised to follow the aftercare protocol from my technician so as to avoid any discomfort or adverse side effects after the procedure has been completed. *
Please type your full name, (if under 18 years of age please also type the parent or guardian's name), below to confirm that you understand and accept these liabilities and policies. *
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy