Luxurious Lashes by Amanda
Informed Consent Form for
Individual Eyelash Extensions Procedure
I, _____________________________, Understand, consent and agree as follows:
I agree to only use recommended products on my new Eyelash Extensions.
I understand that I should not get my Eyelash Extensions wet within the first 24 hours after application.
I understand that there are many variables, including technician’s expertise, hair growth cycle, use of cosmetics and skin care products, and the overall care given, that will influence how long my Eyelash Extensions remain in place.
I acknowledge that iI should not rub my eyes or pull on my lashes after the Eyelash Extensions have been applied.
I understand that if eyelash extensions are not applied properly by certified eyelash technicians, there is a risk of eye damage and harm to my vision.
I have been advised that using mascara on a regular basis can shorten the length of time my extensions remain in place. I have also been advised not to use waterproof mascara on my Eyelash Extensions as it will break down the adhesive.
I understand that touch-up appointments will be necessary a couple weeks after the application and that there will be additional fees for this procedure.
I also realize that the following risks and hazards may occur in connection with any particular treatment, including but not limited to: unsatisfactory results, poor healing, discomfort, redness, and infection. I understand that even though all precautions will be taken in my treatment, not all risks can be known in advance.
I have read and discussed the above information with my Certified Eyelash Technician and authorize the application of the Eyelash Extension products to my own eyelashes.
Client Signature: ___________________________________ Date:________________
Technician Signature:_______________________________ Date:_________________
General Health and Safety Warning
Eyelash Extensions are not for everyone; prior to application, you should notify and discuss with your certified eyelash technician if you have recently or frequently experienced any of the following:
-Unusual sensitivity or skin reaction to cyanoacrylate-based adhesives -Moderate to severe allergies in combination with abnormal eye discharge -Any eye disease or medical condition, such as conjunctivitis (“pink eye”) -A compromised immune system due to cancer treatment, hepatitis, or advanced AIDS -A recent bacterial fungal infection in or around the eye area -Any type of cancer – Alopecia -Skin disease – Any metabolic or endocrine disorder – Blunt trauma in or around the eye area -Intoxication or impaired motor skills due to medications, alcohol, or any other drug.
Never allow uncured cyanoacrylate-based adhesives or removers to contact the eyelid or eyeball. Any uncured cyanoacrylate adhesive or remover in contact with eyelid or the eyeball may cause temporary or permanent eye damage, including temporary or permanent loss of vision or blurred vision. For any reason, if uncured cyanoacrylate adhesive or remover contacts the eye area, immediately flush with large amounts of water and seek immediate medical attention.
Tips for maintenance and care: To maximize the length of time Eyelash Extensions remain in place, Amanda Akers recommends the following:
Only a Certified Eyelash Technician should apply Eyelash Extensions.
Use only recommended cosmetic products and cleansers (see after-care instructions) once the extensions are applied.
Do not get the Eyelash Extensions wet within the first 24 hours after application.
Do not rub your eyes or pull the lashes after the extensions have been applied.
Avoid using mascara on a regular basis, as it can shorten the length of time the extensions remain in place.
Do not use waterproof mascara on your Eyelash Extensions.
After the application, touch-up appointments will be necessary after a couple weeks.
Informed Consent for Procedure
I understand that Eyelash Extensions are semi-permanent and should last about a month. I understand that the lasting beauty and effect are highly variable and are dependent on, among other things, the skill and expertise of the Eyelash Technician, my normal hair growth cycle, my use of cosmetics and skin care products, and my adherence to the instructions for maintenance and care.
I have fully read and understand all of the information on this form. I have been given an opportunity to ask any questions. My Certified Eyelash Technician has fully explained the procedure and answered any questions to my satisfactory. I have sufficient information to give informed consent.
I do not have any condition as noted above, nor any other condition of which I am aware, that would affect the general use or application of eyelash extensions.
I also realize all risks or hazards.
I, ____________________________ give Amanda Akers consent to apply Eyelash Extensions.
Signature _____________________________________ Date __________________________