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Glow Setters Skin Studio – Lash Extensions Waiver & Consultation Form

Lash Extensions Consent & Acknowledgment

I understand that lash extensions involve the application of synthetic or mink lashes to my natural lashes using a professional-grade adhesive.

- I confirm I am not experiencing any eye infection, irritation, or active medical condition that may interfere with the service.

- I acknowledge that adhesive may contain cyanoacrylate and can cause sensitivity or allergic reaction in rare cases.

- I understand that lash extensions require regular fills every 2–3 weeks to maintain fullness.

- I agree not to use oil-based products, waterproof mascara, or mechanical lash curlers.

- I understand I must avoid steam, sweat, and moisture for at least 24–48 hours post-application.

- I understand the natural lash cycle and that premature shedding may occur due to health, hormones, or improper care.

- I will follow all aftercare instructions provided and notify the esthetician immediately of any discomfort.

Waiver of Liability & Legal Release

I understand that despite proper application, adverse reactions such as redness, irritation, burning, allergic reactions, or lash loss may occur. I agree to release Glow Setters Skin Studio, its owners, employees, and contractors from any liability related to lash extension services including injury, adverse reaction, or dissatisfaction with the outcome.

I understand this is a cosmetic service and not a medical treatment. I have answered all questions truthfully to the best of my knowledge and take full responsibility for any complications arising from withheld information or failure to follow pre/post-care instructions.

This waiver shall apply to all future lash services performed unless revoked in writing.

Date: November 30, 2025

First Participant's Name
First Name*
Middle Name
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Information
How did you hear about us?

Medical History & Eye Health

Please check all that apply to you and provide details if applicable:
Eye infections (conjunctivitis, styes, blepharitis)
Chronic dry eye or watery eyes
Allergies to adhesives, latex, cyanoacrylate, or lash products
Contact lenses
Recent eye surgery or LASIK
Use of eye drops or medicated ointments
Pregnancy or breastfeeding
Glaucoma or other eye conditions
Autoimmune or immune-compromised conditions
Skin sensitivities or past reactions to beauty services

If any boxes are checked, please explain:

Lash History & Preferences

Have you ever had lash extensions before? *
No
Yes
If yes, did you experience any reactions or irritation?
Do you currently have lash extensions on? *
No
Yes
Do you wear contact lenses? (Please remove before service)*
No
Yes
Desired style: *
Classic
Hybrid
Volume
Natural
Full Glam
Do you have any sensitivities or preferences we should be aware of?
First Participant's Signature*
Second Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Second Participant's Information
How did you hear about us?

Medical History & Eye Health

Please check all that apply to you and provide details if applicable:
Eye infections (conjunctivitis, styes, blepharitis)
Chronic dry eye or watery eyes
Allergies to adhesives, latex, cyanoacrylate, or lash products
Contact lenses
Recent eye surgery or LASIK
Use of eye drops or medicated ointments
Pregnancy or breastfeeding
Glaucoma or other eye conditions
Autoimmune or immune-compromised conditions
Skin sensitivities or past reactions to beauty services

If any boxes are checked, please explain:

Lash History & Preferences

Have you ever had lash extensions before? *
No
Yes
If yes, did you experience any reactions or irritation?
Do you currently have lash extensions on? *
No
Yes
Do you wear contact lenses? (Please remove before service)*
No
Yes
Desired style: *
Classic
Hybrid
Volume
Natural
Full Glam
Do you have any sensitivities or preferences we should be aware of?
Third Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Information
How did you hear about us?

Medical History & Eye Health

Please check all that apply to you and provide details if applicable:
Eye infections (conjunctivitis, styes, blepharitis)
Chronic dry eye or watery eyes
Allergies to adhesives, latex, cyanoacrylate, or lash products
Contact lenses
Recent eye surgery or LASIK
Use of eye drops or medicated ointments
Pregnancy or breastfeeding
Glaucoma or other eye conditions
Autoimmune or immune-compromised conditions
Skin sensitivities or past reactions to beauty services

If any boxes are checked, please explain:

Lash History & Preferences

Have you ever had lash extensions before? *
No
Yes
If yes, did you experience any reactions or irritation?
Do you currently have lash extensions on? *
No
Yes
Do you wear contact lenses? (Please remove before service)*
No
Yes
Desired style: *
Classic
Hybrid
Volume
Natural
Full Glam
Do you have any sensitivities or preferences we should be aware of?
Fourth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Information
How did you hear about us?

Medical History & Eye Health

Please check all that apply to you and provide details if applicable:
Eye infections (conjunctivitis, styes, blepharitis)
Chronic dry eye or watery eyes
Allergies to adhesives, latex, cyanoacrylate, or lash products
Contact lenses
Recent eye surgery or LASIK
Use of eye drops or medicated ointments
Pregnancy or breastfeeding
Glaucoma or other eye conditions
Autoimmune or immune-compromised conditions
Skin sensitivities or past reactions to beauty services

If any boxes are checked, please explain:

Lash History & Preferences

Have you ever had lash extensions before? *
No
Yes
If yes, did you experience any reactions or irritation?
Do you currently have lash extensions on? *
No
Yes
Do you wear contact lenses? (Please remove before service)*
No
Yes
Desired style: *
Classic
Hybrid
Volume
Natural
Full Glam
Do you have any sensitivities or preferences we should be aware of?
Fifth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Information
How did you hear about us?

Medical History & Eye Health

Please check all that apply to you and provide details if applicable:
Eye infections (conjunctivitis, styes, blepharitis)
Chronic dry eye or watery eyes
Allergies to adhesives, latex, cyanoacrylate, or lash products
Contact lenses
Recent eye surgery or LASIK
Use of eye drops or medicated ointments
Pregnancy or breastfeeding
Glaucoma or other eye conditions
Autoimmune or immune-compromised conditions
Skin sensitivities or past reactions to beauty services

If any boxes are checked, please explain:

Lash History & Preferences

Have you ever had lash extensions before? *
No
Yes
If yes, did you experience any reactions or irritation?
Do you currently have lash extensions on? *
No
Yes
Do you wear contact lenses? (Please remove before service)*
No
Yes
Desired style: *
Classic
Hybrid
Volume
Natural
Full Glam
Do you have any sensitivities or preferences we should be aware of?
Sixth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Information
How did you hear about us?

Medical History & Eye Health

Please check all that apply to you and provide details if applicable:
Eye infections (conjunctivitis, styes, blepharitis)
Chronic dry eye or watery eyes
Allergies to adhesives, latex, cyanoacrylate, or lash products
Contact lenses
Recent eye surgery or LASIK
Use of eye drops or medicated ointments
Pregnancy or breastfeeding
Glaucoma or other eye conditions
Autoimmune or immune-compromised conditions
Skin sensitivities or past reactions to beauty services

If any boxes are checked, please explain:

Lash History & Preferences

Have you ever had lash extensions before? *
No
Yes
If yes, did you experience any reactions or irritation?
Do you currently have lash extensions on? *
No
Yes
Do you wear contact lenses? (Please remove before service)*
No
Yes
Desired style: *
Classic
Hybrid
Volume
Natural
Full Glam
Do you have any sensitivities or preferences we should be aware of?
Seventh Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Information
How did you hear about us?

Medical History & Eye Health

Please check all that apply to you and provide details if applicable:
Eye infections (conjunctivitis, styes, blepharitis)
Chronic dry eye or watery eyes
Allergies to adhesives, latex, cyanoacrylate, or lash products
Contact lenses
Recent eye surgery or LASIK
Use of eye drops or medicated ointments
Pregnancy or breastfeeding
Glaucoma or other eye conditions
Autoimmune or immune-compromised conditions
Skin sensitivities or past reactions to beauty services

If any boxes are checked, please explain:

Lash History & Preferences

Have you ever had lash extensions before? *
No
Yes
If yes, did you experience any reactions or irritation?
Do you currently have lash extensions on? *
No
Yes
Do you wear contact lenses? (Please remove before service)*
No
Yes
Desired style: *
Classic
Hybrid
Volume
Natural
Full Glam
Do you have any sensitivities or preferences we should be aware of?
Eighth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Information
How did you hear about us?

Medical History & Eye Health

Please check all that apply to you and provide details if applicable:
Eye infections (conjunctivitis, styes, blepharitis)
Chronic dry eye or watery eyes
Allergies to adhesives, latex, cyanoacrylate, or lash products
Contact lenses
Recent eye surgery or LASIK
Use of eye drops or medicated ointments
Pregnancy or breastfeeding
Glaucoma or other eye conditions
Autoimmune or immune-compromised conditions
Skin sensitivities or past reactions to beauty services

If any boxes are checked, please explain:

Lash History & Preferences

Have you ever had lash extensions before? *
No
Yes
If yes, did you experience any reactions or irritation?
Do you currently have lash extensions on? *
No
Yes
Do you wear contact lenses? (Please remove before service)*
No
Yes
Desired style: *
Classic
Hybrid
Volume
Natural
Full Glam
Do you have any sensitivities or preferences we should be aware of?
Ninth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Information
How did you hear about us?

Medical History & Eye Health

Please check all that apply to you and provide details if applicable:
Eye infections (conjunctivitis, styes, blepharitis)
Chronic dry eye or watery eyes
Allergies to adhesives, latex, cyanoacrylate, or lash products
Contact lenses
Recent eye surgery or LASIK
Use of eye drops or medicated ointments
Pregnancy or breastfeeding
Glaucoma or other eye conditions
Autoimmune or immune-compromised conditions
Skin sensitivities or past reactions to beauty services

If any boxes are checked, please explain:

Lash History & Preferences

Have you ever had lash extensions before? *
No
Yes
If yes, did you experience any reactions or irritation?
Do you currently have lash extensions on? *
No
Yes
Do you wear contact lenses? (Please remove before service)*
No
Yes
Desired style: *
Classic
Hybrid
Volume
Natural
Full Glam
Do you have any sensitivities or preferences we should be aware of?
Tenth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Information
How did you hear about us?

Medical History & Eye Health

Please check all that apply to you and provide details if applicable:
Eye infections (conjunctivitis, styes, blepharitis)
Chronic dry eye or watery eyes
Allergies to adhesives, latex, cyanoacrylate, or lash products
Contact lenses
Recent eye surgery or LASIK
Use of eye drops or medicated ointments
Pregnancy or breastfeeding
Glaucoma or other eye conditions
Autoimmune or immune-compromised conditions
Skin sensitivities or past reactions to beauty services

If any boxes are checked, please explain:

Lash History & Preferences

Have you ever had lash extensions before? *
No
Yes
If yes, did you experience any reactions or irritation?
Do you currently have lash extensions on? *
No
Yes
Do you wear contact lenses? (Please remove before service)*
No
Yes
Desired style: *
Classic
Hybrid
Volume
Natural
Full Glam
Do you have any sensitivities or preferences we should be aware of?
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Middle Name
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Information
How did you hear about us?

Medical History & Eye Health

Please check all that apply to you and provide details if applicable:
Eye infections (conjunctivitis, styes, blepharitis)
Chronic dry eye or watery eyes
Allergies to adhesives, latex, cyanoacrylate, or lash products
Contact lenses
Recent eye surgery or LASIK
Use of eye drops or medicated ointments
Pregnancy or breastfeeding
Glaucoma or other eye conditions
Autoimmune or immune-compromised conditions
Skin sensitivities or past reactions to beauty services

If any boxes are checked, please explain:

Lash History & Preferences

Have you ever had lash extensions before? *
No
Yes
If yes, did you experience any reactions or irritation?
Do you currently have lash extensions on? *
No
Yes
Do you wear contact lenses? (Please remove before service)*
No
Yes
Desired style: *
Classic
Hybrid
Volume
Natural
Full Glam
Do you have any sensitivities or preferences we should be aware of?
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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