Eyelash Extension Agreement / Consent Form
Full Name:_______________________________________
Telephone: (Cell) __________________________________
Email: ___________________________________________
Referred by: _______________________________________
Initial:
_______ I understand that this procedure requires single and/or multiple synthetic eyelashes to be adhered
to my own natural eyelashes.
_______ I understand that it is my responsibility to keep my eyes closed and to be still during the entire
procedure, until my eyelash stylist addresses me to open my eyes.
_______ I understand that some risks of this procedure may be, but not limited to, eye redness and
irritation. The fumes from the adhesive may cause my eyes to tear up if I open my eyes.
________ I have informed my lash stylist of any chronic conditions that may cause an irritation/reaction
from this procedure. (Ex:Blepharitis)
________ I understand that I am required to follow the eyelash extension aftercare sheet in order to
maintain the life of these extensions.
________ I agree that by reading and signing this consent form, I release The Lash Technicians and
Jeunesse Medical Spa from any claims or damages of any nature.
________ I am of sound mind and fully capable of executing this waiver for myself. I am at least 18
years of age or have had a guardian/parent read and sign this form.
________ I give The Lash Technicians and Jeunesse Medical Spa permission to post my before and after
photos/videos of eyelashes for business purposes on websites and/or social media.
