SBL Skin Boost Lab
Eyelash Extensions Consent Form
Street Address Line 2
State / Province
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
Cocos (Keeling) Islands
Democratic Republic of the Congo
Turkish Republic of Northern Cyprus
Papua New Guinea
Republic of the Congo
Saint Kitts and Nevis
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
Tristan da Cunha
Turks and Caicos Islands
United Arab Emirates
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
1.I understand that a full set of lash extensions can make the appearance of my own lashes about30-50% thicker, and make my lashes appear 20-50% long.
2. 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 I understand that lash extension services have some inherent risk of irritation to the orbital eyearea, including the eye itself, and could result in stinging and burning, blurry vision and potentialblindness should the adhesive enter the eye or should an allergic reaction occur. potentialblindness should the adhesive enter the eye or should an allergic reaction occur.
3. I understand that some irritation, itching or burning may occur on the skin if the bonding agent comesinto contact with it
4. I understand that if the bonding agent comes into contact with my eye, my eye will be ushed withwater and I will be assisted in seeking medical attention immediately
5. I understand that this is a semi-permanent procedure, as my natural lashes will continue to growand fall out normally, making touch-up or “ ll” appointments necessary to maintain the original lookachieved by replacing the lashes that have fallen out. Most clients require a ll appointment every 2-3weeks.
6. I understand that while every attempt will be made to provide me with the length and fullness I havechosen, my nal result may not be what I initially envisioned.
7. I understand that it is imperative that I disclose all of the information requested in the Client Pro le/Health History
8. I have cited all conditions and circumstances regarding my health history, medications being taken,and any past reactions to products or medications.
9. I understand that additional conditions could occur or be discovered during the procedure whichcould a ect my ability to tolerate the procedure.
10. I consent to “before and after” photographs for the purpose of documentation, potential advertisingand promotional purposes.
I understand that if I have any concerns, I will address these with my lash extension specialist. I givepermission to my lash extension specialist to perform the lash extension procedure we have discussed,and will hold him/her and his/her sta harmless and nameless from any liability that may result from thistreatment. I have accurately answered the questions above, including all known allergies, prescriptiondrugs, or products I am currently ingesting or using topically. I understand my lash extension specialistwill 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 extensionspecialist immediately. I agree that this constitutes full disclosure, and that it supersedes any previousverbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs andthat I have had su cient opportunity for discussion to have any questions answered. I understand theprocedure and accept the risks. I do not hold the lash extension specialist, whose signature appearsbelow, responsible for any of my conditions that were present, but not disclosed at the time of thisprocedure, which may be a ected by the treatment performed today. (type Your Last Name in the box please)
Are you removing your Lash Extensions (if Yes Answer the Following Questions)
Are you allergic to the following ingredients
I understand Eyelash Extension may cause irritation, redness, itchiness, dryness, minor swelling
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