EYELASH EXTENSIONS CONSENT FORM

First Name *

Last Name *

Phone *

Email *

Date of birth

Age

Address

City

State

MEDICAL HISTORY

Have you had eyelash extensions before?

Yes

Do you have any additional allergies such as to metals, soaps, cosmetics or alcohol?

Do you have any other medical or skin conditions that affect the outcome of your procedure?

Eyelash extensions: if you have any medical condition above

I confirm that I have a medical condition, and I have consulted with a healthcare professional/doctor regarding this condition. My healthcare professional/doctor has advised me that eyelash extension is safe for me to undergo, given my medical condition.

PLEASE READ AND CHECK THE BOXES WHEN YOU ARE CERTAIN YOU UNDERSTAND THE IMPLICATIONS OF SIGNING

In consideration of receiving eyelash extensions from Milia Duong, Permanent Makeup By Milia (together with its employees, apprentices, and agents:

Eyelash Extensions: check all the boxes below to confirm:

I hereby agree to have eyelash extensions applied to my natural lashes and consent to the placement and/or removal of the eyelash extensions by the certified professional.

I understand and agree to the after-care instructions and for any unexpected circumstance that have happened due to not following these instructions are in my own risk.

I hereby grant permission for pictures and videos of my procedure to be taken. I understand and agree that these images may be used for record-keeping purposes and/or promotional and advertising materials.

I understand that in rare occasions there are risks associated with having artificial eyelashes. I further understand that in rare circumstances eye or skin irritation and discomfort may occur.

I understand that because of the natural lash cycle and wear and tear, I will need to maintain my extensions with touch up appointments usually recommend about every 2 to 3 weeks to keep them full.

AFTERCARE INSTRUCTIONS

The following written instructions were communicated to the client:

1. Keep Dry for 24 Hours: Avoid getting your lashes wet for the first 24 hours to allow the glue to fully set.

2. Be Gentle: Avoid rubbing your eyes and be gentle when cleansing your face. Use a soft, oil-free cleanser around the eye area.

3. Avoid Oil-Based Products: Oils can weaken the adhesive. Use oil-free makeup and makeup removers.

4. No Mascara Needed: Your extensions give the fullness and length mascara does, so you don’t need it. If you must, use water-based mascara on the tips only.

5. Brush Daily: Gently brush your lash extensions with a clean, soft lash brush to keep them aligned and neat.

6. Avoid Heat: Keep your lashes away from direct heat sources like hairdryers, as heat can cause the lashes to lose shape.

7. Sleep Carefully: Try to sleep on your back to avoid crushing your lashes.

8. Regular Touch-Ups: Schedule touch-up appointments every 2-3 weeks to maintain your lash look.

9. No Picking or Pulling: Avoid picking or pulling on your lash extensions as this can damage your natural lashes.

10. Contact Us for Any Issues: If you experience any discomfort or have concerns about your lash extensions, please contact us immediately.

Artist Name

Date Signed *

Signature *

Clear

By providing my phone number, I agree to receive text messages from the business regarding aftercare instructions, appointment reminders, and promotions.