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Before my qualified professional eyelash technician can perform this procedure, I understand I must complete and sign this consent form.
Yes
No
Date
*
MM slash DD slash YYYY
Technician
*
Treatment
*
Patch test date
MM slash DD slash YYYY
I agree to a patch test of the products used during treatment, I will notify staff immediately if I have any adverse reaction that may cause the treatment to cancelled or abandoned
Clients Name
*
First
Last
Address
*
Street Address
Address Line 2
City
County
Postcode
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
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Aruba
Australia
Austria
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Bahamas
Bahrain
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Belgium
Belize
Benin
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Bhutan
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Bosnia and Herzegovina
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Bouvet Island
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Bulgaria
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Central African Republic
Chad
Chile
China
Christmas Island
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Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
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Grenada
Guadeloupe
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Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
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Macedonia
Madagascar
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Malaysia
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Mali
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Martinique
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Mauritius
Mayotte
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Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Contact Number
Date of birth
*
MM slash DD slash YYYY
Email
*
Medical information (please tick if yes)
Allergies
Specific allergies to adhesives
Chemotherapy (last 6 months)
Thyroid medication
Lasik surgery (less than 4 months) (Must wait 4 weeks post op for medical exam)
Blethoroplasty (must wait 6 months post op for medial consent)
Contact lenses
Extremely oily skin or hair
Plasma in eye area
Recent permanent makeup (eyeliner)
Lash growth serums
If yes to any of above, please give details.
I have agreed to have eyelash extensions applied and/or removed from my natural lashes.
*
Yes
I understand there are risks associated with having artificial eyelashes applied to and/or removed from my natural lashes
*
Yes
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, thereby preserving the health, growth and natural look of the clients natural eyelashes.
*
Yes
I understand as part of the procedure eye irritation, eye pain, eye itching, discomfort and in very rare cases an eye infection may occur, I understand and agree that if I experience any of these issues with my lashes or eyes I will contact my technician and have the lashes removed immediately and consult a physician at my own expense
*
Yes
I understand that even though the technician may apply and remove the eyelashes properly, that adhesive materials may become dislodged during or after the procedure, which may irritate the eyes or require further follow up care.
*
Yes
I understand and agree to follow the aftercare instructions provided by my technician. Failure to follow the aftercare instructions can lead to poor results.
*
Yes
I understand that in order to have my eyelash extensions applied I will need to be laying in a reclined position and keep my eyes closed for a duration of 60-100 minutes during the treatment. Any medical reason that prevents this will result in refusal of treatment.
*
Yes
This agreement will remain in effect for the procedure and all future treatments, I agree to sign a subsequent visit form on each visit to declare any changes in circumstances.
*
Yes
TREATMENT LOG
Treatment
Treatment log
Before image
Before image
Before image
After image
After image
After image
TO BE COMPLETED AFTER TREATMENT
I am happy with the way my technician has applied my eyelash extensions
Date
MM slash DD slash YYYY
I confirm I have received the aftercare instructions
Date
MM slash DD slash YYYY
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