I agree to have eyelash extensions applied to my natural eyelashes and/or removed
and retouched. By signing this agreement, I consent to the placement and/or removal of the eyelash extensions
by the certified eyelash extension professional.
_______ 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 lashes that I will contact
the certified eyelash extension professional that performed this procedure and it may be beneficial to have the eyelashes
_______ I understand and agree to the after-care instructions provided by the certified eyelash extension professional for
the use and care of my eyelash extensions. I realize and accept the consequences of failure to adhere to these instructions
may cause the eyelash extensions to fall out and/or decrease the time the lashes will last.
_______ I understand and consent to having my eyes closed and covered for the duration of approximately 60-120 minute
procedure. Times may vary depending on the type and number of eyelashes applied.
_______ I am informing the certified eyelash extension professional of the following conditions by marking with a check:
Current use of contact lenses which I may be asked to remove during the procedure
Current use of anything such as oil-containing sunscreen or moisturizers around the eyes
Current use of eye drops of any kind, prescription or over-the-counter
Current allergies or sensitivities
History of recurrent eye or tear duct infections
History of dry eyes or Sjorgen’s Syndrome
Recent history of Chemotherapy
Other medical conditions which would prohibit or compromise placement and retention of eyelash extensions
_______ I agree to the following eyelash extension follow-up and maintenance instructions:
No waterproof mascara
No oil based products around the eye area
No water can come in contact with the eye area for 24 hours after the application
No tinting or perming of eyelash extensions
No pulling or rubbing of the eyelash extensions
Should any kind of eye drops be necessary extra care should be taken to prevent moisture from coming into contact with the eyelash extensions
This agreement will remain in effect for this procedure and all future follow-ups conducted by the certified eyelash
extension professional. I read English and understand that this consent agreement is legal and binding. I have read and
fully understand all information in this agreement. I am over 18 years of age and consent to the agreement and to the
eyelash extension application procedure.
EYELASH EXTENSION CONSENT FORM