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Client Health History & Informed Consent: Lash Extensions 


First Client's Name

First Name*

Middle Name

Last Name*

Phone*
First Client's Date of Birth*
First Client's Health History

Please list any allergies you have (including cosmetics/ingredients):
Are you allergic to Acrylate/Cyanocarylate (bonding agent)?*
No
Yes
Don't know
Have you ever had a reaction to adhesive tape, topical creams, nail adhesives, or other topical products?*
No
Yes
Do you have any eye disease, condition or injury that has affected your hair/lash growth or loss? *
No
Yes

Please list all current medications you are taking (including over-the-counter herbs, vitamins and supplements):
Have you ever had any of these conditions? (Please check all that apply)
Alopecia
Asthma
Back pain or back injury
Bell’s Palsy
Blepharitis
Claustrophobia
Cold Sores
Conjunctivitis (pink eye)
Diabetes
Dry Eye Syndrome
Eye Sties or Sores
Herpes of the Eye
Intense Stress
Leamy eye
Light Sensitivity
Migraines
Ocular Rosacea
Rosacea
Sensitive Eyes
Stroke/TIA
Thyroid Disease
Trichotillomania
Recent Eye Surgery
Current Eye Irritation

Any other health condition not listed:
First Client's Signature*
Second Client's Name

First Name*

Middle Name

Last Name*
Second Client's Date of Birth*
Second Client's Health History

Please list any allergies you have (including cosmetics/ingredients):
Are you allergic to Acrylate/Cyanocarylate (bonding agent)?*
No
Yes
Don't know
Have you ever had a reaction to adhesive tape, topical creams, nail adhesives, or other topical products?*
No
Yes
Do you have any eye disease, condition or injury that has affected your hair/lash growth or loss? *
No
Yes

Please list all current medications you are taking (including over-the-counter herbs, vitamins and supplements):
Have you ever had any of these conditions? (Please check all that apply)
Alopecia
Asthma
Back pain or back injury
Bell’s Palsy
Blepharitis
Claustrophobia
Cold Sores
Conjunctivitis (pink eye)
Diabetes
Dry Eye Syndrome
Eye Sties or Sores
Herpes of the Eye
Intense Stress
Leamy eye
Light Sensitivity
Migraines
Ocular Rosacea
Rosacea
Sensitive Eyes
Stroke/TIA
Thyroid Disease
Trichotillomania
Recent Eye Surgery
Current Eye Irritation

Any other health condition not listed:
Third Client's Name

First Name*

Middle Name

Last Name*
Third Client's Date of Birth*
Third Client's Health History

Please list any allergies you have (including cosmetics/ingredients):
Are you allergic to Acrylate/Cyanocarylate (bonding agent)?*
No
Yes
Don't know
Have you ever had a reaction to adhesive tape, topical creams, nail adhesives, or other topical products?*
No
Yes
Do you have any eye disease, condition or injury that has affected your hair/lash growth or loss? *
No
Yes

Please list all current medications you are taking (including over-the-counter herbs, vitamins and supplements):
Have you ever had any of these conditions? (Please check all that apply)
Alopecia
Asthma
Back pain or back injury
Bell’s Palsy
Blepharitis
Claustrophobia
Cold Sores
Conjunctivitis (pink eye)
Diabetes
Dry Eye Syndrome
Eye Sties or Sores
Herpes of the Eye
Intense Stress
Leamy eye
Light Sensitivity
Migraines
Ocular Rosacea
Rosacea
Sensitive Eyes
Stroke/TIA
Thyroid Disease
Trichotillomania
Recent Eye Surgery
Current Eye Irritation

Any other health condition not listed:
Fourth Client's Name

First Name*

Middle Name

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Health History

Please list any allergies you have (including cosmetics/ingredients):
Are you allergic to Acrylate/Cyanocarylate (bonding agent)?*
No
Yes
Don't know
Have you ever had a reaction to adhesive tape, topical creams, nail adhesives, or other topical products?*
No
Yes
Do you have any eye disease, condition or injury that has affected your hair/lash growth or loss? *
No
Yes

Please list all current medications you are taking (including over-the-counter herbs, vitamins and supplements):
Have you ever had any of these conditions? (Please check all that apply)
Alopecia
Asthma
Back pain or back injury
Bell’s Palsy
Blepharitis
Claustrophobia
Cold Sores
Conjunctivitis (pink eye)
Diabetes
Dry Eye Syndrome
Eye Sties or Sores
Herpes of the Eye
Intense Stress
Leamy eye
Light Sensitivity
Migraines
Ocular Rosacea
Rosacea
Sensitive Eyes
Stroke/TIA
Thyroid Disease
Trichotillomania
Recent Eye Surgery
Current Eye Irritation

Any other health condition not listed:
Fifth Client's Name

First Name*

Middle Name

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Health History

Please list any allergies you have (including cosmetics/ingredients):
Are you allergic to Acrylate/Cyanocarylate (bonding agent)?*
No
Yes
Don't know
Have you ever had a reaction to adhesive tape, topical creams, nail adhesives, or other topical products?*
No
Yes
Do you have any eye disease, condition or injury that has affected your hair/lash growth or loss? *
No
Yes

Please list all current medications you are taking (including over-the-counter herbs, vitamins and supplements):
Have you ever had any of these conditions? (Please check all that apply)
Alopecia
Asthma
Back pain or back injury
Bell’s Palsy
Blepharitis
Claustrophobia
Cold Sores
Conjunctivitis (pink eye)
Diabetes
Dry Eye Syndrome
Eye Sties or Sores
Herpes of the Eye
Intense Stress
Leamy eye
Light Sensitivity
Migraines
Ocular Rosacea
Rosacea
Sensitive Eyes
Stroke/TIA
Thyroid Disease
Trichotillomania
Recent Eye Surgery
Current Eye Irritation

Any other health condition not listed:
Sixth Client's Name

First Name*

Middle Name

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Health History

Please list any allergies you have (including cosmetics/ingredients):
Are you allergic to Acrylate/Cyanocarylate (bonding agent)?*
No
Yes
Don't know
Have you ever had a reaction to adhesive tape, topical creams, nail adhesives, or other topical products?*
No
Yes
Do you have any eye disease, condition or injury that has affected your hair/lash growth or loss? *
No
Yes

Please list all current medications you are taking (including over-the-counter herbs, vitamins and supplements):
Have you ever had any of these conditions? (Please check all that apply)
Alopecia
Asthma
Back pain or back injury
Bell’s Palsy
Blepharitis
Claustrophobia
Cold Sores
Conjunctivitis (pink eye)
Diabetes
Dry Eye Syndrome
Eye Sties or Sores
Herpes of the Eye
Intense Stress
Leamy eye
Light Sensitivity
Migraines
Ocular Rosacea
Rosacea
Sensitive Eyes
Stroke/TIA
Thyroid Disease
Trichotillomania
Recent Eye Surgery
Current Eye Irritation

Any other health condition not listed:
Seventh Client's Name

First Name*

Middle Name

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Health History

Please list any allergies you have (including cosmetics/ingredients):
Are you allergic to Acrylate/Cyanocarylate (bonding agent)?*
No
Yes
Don't know
Have you ever had a reaction to adhesive tape, topical creams, nail adhesives, or other topical products?*
No
Yes
Do you have any eye disease, condition or injury that has affected your hair/lash growth or loss? *
No
Yes

Please list all current medications you are taking (including over-the-counter herbs, vitamins and supplements):
Have you ever had any of these conditions? (Please check all that apply)
Alopecia
Asthma
Back pain or back injury
Bell’s Palsy
Blepharitis
Claustrophobia
Cold Sores
Conjunctivitis (pink eye)
Diabetes
Dry Eye Syndrome
Eye Sties or Sores
Herpes of the Eye
Intense Stress
Leamy eye
Light Sensitivity
Migraines
Ocular Rosacea
Rosacea
Sensitive Eyes
Stroke/TIA
Thyroid Disease
Trichotillomania
Recent Eye Surgery
Current Eye Irritation

Any other health condition not listed:
Eighth Client's Name

First Name*

Middle Name

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Health History

Please list any allergies you have (including cosmetics/ingredients):
Are you allergic to Acrylate/Cyanocarylate (bonding agent)?*
No
Yes
Don't know
Have you ever had a reaction to adhesive tape, topical creams, nail adhesives, or other topical products?*
No
Yes
Do you have any eye disease, condition or injury that has affected your hair/lash growth or loss? *
No
Yes

Please list all current medications you are taking (including over-the-counter herbs, vitamins and supplements):
Have you ever had any of these conditions? (Please check all that apply)
Alopecia
Asthma
Back pain or back injury
Bell’s Palsy
Blepharitis
Claustrophobia
Cold Sores
Conjunctivitis (pink eye)
Diabetes
Dry Eye Syndrome
Eye Sties or Sores
Herpes of the Eye
Intense Stress
Leamy eye
Light Sensitivity
Migraines
Ocular Rosacea
Rosacea
Sensitive Eyes
Stroke/TIA
Thyroid Disease
Trichotillomania
Recent Eye Surgery
Current Eye Irritation

Any other health condition not listed:
Ninth Client's Name

First Name*

Middle Name

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Health History

Please list any allergies you have (including cosmetics/ingredients):
Are you allergic to Acrylate/Cyanocarylate (bonding agent)?*
No
Yes
Don't know
Have you ever had a reaction to adhesive tape, topical creams, nail adhesives, or other topical products?*
No
Yes
Do you have any eye disease, condition or injury that has affected your hair/lash growth or loss? *
No
Yes

Please list all current medications you are taking (including over-the-counter herbs, vitamins and supplements):
Have you ever had any of these conditions? (Please check all that apply)
Alopecia
Asthma
Back pain or back injury
Bell’s Palsy
Blepharitis
Claustrophobia
Cold Sores
Conjunctivitis (pink eye)
Diabetes
Dry Eye Syndrome
Eye Sties or Sores
Herpes of the Eye
Intense Stress
Leamy eye
Light Sensitivity
Migraines
Ocular Rosacea
Rosacea
Sensitive Eyes
Stroke/TIA
Thyroid Disease
Trichotillomania
Recent Eye Surgery
Current Eye Irritation

Any other health condition not listed:
Tenth Client's Name

First Name*

Middle Name

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Health History

Please list any allergies you have (including cosmetics/ingredients):
Are you allergic to Acrylate/Cyanocarylate (bonding agent)?*
No
Yes
Don't know
Have you ever had a reaction to adhesive tape, topical creams, nail adhesives, or other topical products?*
No
Yes
Do you have any eye disease, condition or injury that has affected your hair/lash growth or loss? *
No
Yes

Please list all current medications you are taking (including over-the-counter herbs, vitamins and supplements):
Have you ever had any of these conditions? (Please check all that apply)
Alopecia
Asthma
Back pain or back injury
Bell’s Palsy
Blepharitis
Claustrophobia
Cold Sores
Conjunctivitis (pink eye)
Diabetes
Dry Eye Syndrome
Eye Sties or Sores
Herpes of the Eye
Intense Stress
Leamy eye
Light Sensitivity
Migraines
Ocular Rosacea
Rosacea
Sensitive Eyes
Stroke/TIA
Thyroid Disease
Trichotillomania
Recent Eye Surgery
Current Eye Irritation

Any other health condition not listed:
Parent or Guardian's Email Address

Email*

Confirm Email*
These questions are relevant to your hair growth, and overall hair health. Please answer as fully as possible.
Are you pregnant or nursing?*
No
Yes
Do you wear contacts?*
No
Yes
Do you wear glasses?*
No
Yes
Have you ever had lash extensions?*
No
Yes
Have you ever had lash extensions removed?*
No
Yes
Have you ever used long lasting or waterproof cosmetics?*
No
Yes

If yes, please specify:
Do you use Retin-A or Accutane?*
No
Yes
Do you go tanning (in salon, outdoor, or spray tan)?*
No
Yes
Have you had facial treatments?*
No
Yes
Have you ever had Botox®, Juvederm®, or any other injectables?*
No
Yes
Have you ever used Latisse® or any other lash growing product?*
No
Yes
Which side do you most often sleep on? (check all that apply)
Right
Left
Stomach
Back
How fast do you feel your hair grows?
Fast
Slow
Normal Rate

Is there anything else we should know about?
Informed Consent: Lash Extensions
Although every precaution will be taken to ensure your safety and wellbeing before, during and after your lash extension application, please be aware of the following information and possible risks. Please check all boxes to confirm you have read and understand:
I understand that a full set of lash extensions can make the appearance of my own lashes about 30-50% thicker, and make my lashes appear 20-50% longer.
I understand that lash extension services have some inherent risk of irritation to the orbital eye area, including the eye itself, and could result in stinging and burning, blurry vision and potential blindness should the adhesive enter the eye or should an allergic reaction occur.
I understand that some irritation, itching or burning may occur on the skin if the bonding agent comes into contact with it.
I understand that if the bonding agent comes into contact with my eye, my eye will be flushed with water and I will be assisted in seeking medical attention immediately.
I understand that this is a semi-permanent procedure, as my natural lashes will continue to grow and fall out normally, making touch-up or “fill” appointments necessary to maintain the original look achieved by replacing the lashes that have fallen out. Most clients require a fill appointment every 2-3 weeks.
I understand that while every attempt will be made to provide me with the length and fullness I have chosen, my final result may not be what I initially envisioned.
I understand that it is imperative that I disclose all of the information requested in the Client Profile/Health History.
I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications.
I understand that additional conditions could occur or be discovered during the procedure which could affect my ability to tolerate the procedure.
I consent to “before and after” photographs for the purpose of documentation, potential advertising and promotional purposes.
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*
Parent or Guardian's Health History

Please list any allergies you have (including cosmetics/ingredients):
Are you allergic to Acrylate/Cyanocarylate (bonding agent)?*
No
Yes
Don't know
Have you ever had a reaction to adhesive tape, topical creams, nail adhesives, or other topical products?*
No
Yes
Do you have any eye disease, condition or injury that has affected your hair/lash growth or loss? *
No
Yes

Please list all current medications you are taking (including over-the-counter herbs, vitamins and supplements):
Have you ever had any of these conditions? (Please check all that apply)
Alopecia
Asthma
Back pain or back injury
Bell’s Palsy
Blepharitis
Claustrophobia
Cold Sores
Conjunctivitis (pink eye)
Diabetes
Dry Eye Syndrome
Eye Sties or Sores
Herpes of the Eye
Intense Stress
Leamy eye
Light Sensitivity
Migraines
Ocular Rosacea
Rosacea
Sensitive Eyes
Stroke/TIA
Thyroid Disease
Trichotillomania
Recent Eye Surgery
Current Eye Irritation

Any other health condition not listed:
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, I understand that if I have any concerns, I will address these with my lash extension specialist. I give permission to my lash extension specialist to perform the lash extension procedure we have discussed, and will hold him/her and his/her staff harmless and nameless from any liability that may result from this treatment. I have accurately answered the questions above, including all known allergies, prescription drugs, or products I am currently ingesting or using topically. I understand my lash extension specialist will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult the lash extension specialist immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the lash extension specialist, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today.


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