Eyelash Extension Consent Form
Sign in to Google to save your progress. Learn more
NAME *
PHONE NUMBER *
DATE OF BIRTH *
MM
/
DD
/
YYYY
STREET ADDRESS, CITY, STATE, ZIP CODE *
HOW DID YOU FIND US? *
IF YOU WERE REFFERED, BY WHO?
LIFESTYLE: *
Required
WHAT SIDE DO YOU PRIMARILY SLEEP ON? *
By signing and proceeding with your lash appointment you will acknowledge that eyelash extensions carry certain inherit and possible risks of allergic reactions at any time (including, but not limited to) redness, irritations from the chemicals in the adhesives used, itching, swelling, and/or other symptoms of ocular distress that are beyond your practitioners responsibility or control. It is strongly advised to go to your doctor. The adhesives and adhesive removers are both an eye and skin irritant, and you can become allergic to the ingredients in the adhesive at any time. *
I understand that there are some risks with any procedure. The following are possible reactions with Micro needling: temporary bruising, skin discomfort during injections, redness or swelling, lightening or darkening of  the skin, itching and burning. Skin infection is a possibility any time an injection or surgical procedure is done.  Side effects are most of the time temporary and typically resolve within 3 days. Total healing time depends on the  depth of the treatment, skin type, and skin condition, and some patients may heal completely in 24 hours. By my signature, I certify that I have thoroughly read and understood the contents of this form and the  disclosures listed above were made to me. I acknowledge that no promises or guarantees have been made to me as  a result of the treatment. *
If you need to seek medical attention, you must do so and at your own expense. While there are no refunds for this service once applied, removal within 48 hours is complementary, otherwise a removal fee will apply. *
If you experience any discomfort in the first 24-48 hours after application, please call to havethe extension removed. *
I have read potential risks have been explained to me, and I accept them. *
FULL NAME, USED AS SIGNATURE *
TODAY'S DATE *
MM
/
DD
/
YYYY
TIME *
Time
:
IF UNDER THE AGE OF 18, PARENT/GUARDIAN NAME, USED AS SIGNATURE *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms