Informed Consent and Liability Release for Eyelash Extension Services

Procedure Name

Form Sections

Section 1info grid

Salon or Facility Name

Certified Lash Technician

Client Full Legal Name

Date of Birth

Planned Lash Style / Curl Type

Adhesive Sensitivity Level

Patch Test Completed

Date of Consent

Section 2text block

Section 3list block

Section 4text block

Section 5text block

Section 6signature block

Client Signature

Technician Signature

Informed Consent and Liability Release for Eyelash Extension Services

Section 1: Client and Esthetician Information

Salon or Facility Name

Certified Lash Technician

Client Full Legal Name

Date of Birth

Planned Lash Style / Curl Type

Adhesive Sensitivity Level

Patch Test Completed

Date of Consent

Section 2: Nature of Eyelash Extension Application

Eyelash extension application is a cosmetic procedure in which individual synthetic lashes are bonded to the client's natural eyelashes using professional medical-grade cyanoacrylate adhesive. The client will remain reclined with eyes closed throughout the application, which typically takes 1.5 to 3 hours for a full set. The natural lashes are cleansed and isolated, and extensions are applied one by one approximately 0.5 to 1 millimeter away from the eyelid skin to prevent follicle damage. Standard eyelash shedding occurs naturally, so touch-ups (fills) are recommended every 2 to 3 weeks to maintain full appearance.

Section 3: Material Risks and Contraindications

Allergic reaction to adhesive: cyanoacrylate adhesives emit fumes that can trigger redness, itching, swelling, or blistering of the eyelids. This reaction can develop immediately or after several applications.

Eye irritation or corneal abrasion: if adhesive contacts the eye, or if under-eye pads shift during the procedure, minor scratches or chemical irritation to the cornea may occur.

Natural lash shedding: extensions are bonded to natural lashes, which naturally shed 2 to 5 lashes per day. The extension will fall out with the natural lash. Pulling or rubbing extensions will cause premature natural lash loss.

Blepharitis or follicular infection: poor hygiene or failing to wash the lashes daily can lead to a buildup of oils, makeup, and bacteria, causing eyelid inflammation or infection.

Contact lens precaution: contact lenses must be removed prior to the application to prevent adhesive fumes from trapping moisture against the cornea.

Section 4: Aftercare and Maintenance Guidelines

To maximize retention and protect natural lash health, you must follow these aftercare rules: (1) Avoid exposing lashes to water, steam, sweat, or saunas for the first 24 to 48 hours to allow the adhesive bond to fully cure. (2) Do not use oil-based eye makeup, makeup removers, cleansers, or face oils, as oil breaks down the adhesive bond. (3) Wash lashes daily with a lash-safe foaming cleanser and brush them gently with a clean spoolie when dry. (4) Do not use manual lash curlers, waterproof mascara, or eyeliner. (5) Avoid sleeping on your stomach or face. (6) Do not pull, pick, or attempt to remove extensions yourself; professional removal is required to prevent natural lash damage.

Section 5: Liability Release and Acknowledgment

I acknowledge that I have been informed of the nature of the application, aftercare rules, and risks including allergic reactions. I understand that individual results and lash retention vary. I release the salon, facility, and certified technician from liability for any adverse reactions, infections, or injuries resulting from the lash extension service, except in cases of gross negligence.

Section 6: Signatures and Verification

Client Signature

Technician Signature

Document ID: CC-PENDING

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