Agreement Form – Lashmama – Adelaide lashes by Purni

Eyelash Extensions Consent & Agreement Form

Full Name

Contact Infomation

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I understand that this procedure requires single synthetic / Pre-made false eyelashes to be glued to my own natural eyelashes.

I understand that it is my responsibility to keep my eyes closed and be still during the entire procedure, until my eyelash technician 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 agree to disclose any allergies that I may have to latex, surgical tapes, Cyanoacrylate, Vaseline, etc.

I understand that I am required to follow the eyelash extensions care sheet (attached) in order to achieve maximum retention.

I agree that there will be no refunds given after treatment for a change of mind.

I agree that by reading and signing this consent form, I release PURNIMA RANASINHA t/a ADELAIDE LASHES BY PURNI and its representatives and licensed technicians of all claims and injury, seen or unseen that may occur as a result of this procedure.

I have been informed of potentially harmful or negative side effects that may be cause by the application and/or removal of Eyelash Extensions.

I have read and completed the Eyelash Extensions Agreement and Consent Form in its entirety and have answered everything to the best of my ability.

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Cltent Health / Record Form

Birthday

Medical Record

Your health is very important to our professional care of your eyes during the procedure of eyelash extensions. Please circle any of the following that are relevant to your health, and fill in the name where necessary.

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Client Profile

Please fill out the following also:

Have you had eyelash extensions before?

YesNo

If you had eyelash extensions before, when did you get them?

From where did you get your lashes done before (Optional)

How did you hear about us (If by a friend, please write the name of the friend)

Do you like to wear a lot of mascara

YesNo

Do you curl your lashes

YesNo

Do you prefer natural look or bold look

YesNo

Did you experience any adverse reaction?

if so, what?

I acknowledge that the responses I have given are correct to the best of my knowledge that I have not withheld any information that may be relevant to my treatment. I agreed r that by reading and nd signing this ethnic consent means of form, I release Purnima Ranasinha t/a Adelaide Lashes by Purni and its representative's licensed tall claims and injury, seen or unseen that may occur as a result of this procedure(Eyelash Extensions).

Signature

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