LASHES CONSENT FORM

LASHES CONSENT FORM

PATIENT INFORMATION:

First Name

Last Name

Date Of Birth

Phone/Mobile

City

Next Of Kin

Kins Contact Number (Phone/Mobile)

MEDICAL HISTORY

Have you had any recent eye surgery or medical procedures involving the eye area?

Yes

If Yes, please specify:

Do you currently have any eye conditions or infections (e.g., redness, irritation, conjunctivitis, swelling)?

Yes

If Yes, please specify:

Do you have any known allergies or sensitivities to adhesives, lash glue, or cosmetic chemicals?

Yes

If Yes, please specify:

Have you completed a patch test for lash glue at least 24–48 hours prior to this treatment?

Yes

Are you currently wearing contact lenses, and are you willing to remove them before the procedure?

Yes

If No, please specify why:

Do you have any relevant other medical condition?

Yes

If Yes, please specify:

Procedure Description:

I understand that I am receiving UV lash extensions or traditional glue-based lash extensions.

Lash extension procedures involve the application of individual synthetic lashes to my natural lashes using a medical-grade adhesive or UV-activated bonding system.

I understand that:

A patch test is strongly recommended prior to treatment, to reduce the risk of allergic reactions.
I must arrive without eye makeup, including mascara or eyeliner.
I should avoid caffeine (e.g., coffee) before the appointment, as it may cause eye sensitivity or fluttering during the procedure.
Contact lenses must be removed before the procedure begins.

During the treatment, I will be required to keep my eyes closed for an extended period while products are carefully applied near the eye area.

I understand that the procedure is non-invasive but requires precision and care, and results vary depending on my natural lashes and adherence to aftercare.

Benefits and Risks:

I have been informed that the potential benefits of these treatments may include:

Enhanced length, volume, and definition of eyelashes
Reduced need for daily makeup (mascara)
Long-lasting cosmetic enhancement with proper care

I understand that there are potential risks and side effects associated with these treatments, including:

Temporary redness or irritation of the eyes or surrounding skin
Watery eyes during or after the procedure (this is normal and may occur even when products are properly applied)
Allergic reactions to adhesives
Burning or stinging sensation if products come into contact with the eyes
Temporary blurred vision due to watering or sensitivity

I understand that serious complications are uncommon but may occur in rare cases.

Aftercare:

I agree to follow the post-treatment instructions provided by the clinician to ensure the best possible results and minimize any risks. I understand that failure to adhere to these instructions may increase the likelihood of complications.

Consent for Treatment:

I hereby consent to receive UV lash extensions or traditional glue-based lash extensions. I acknowledge that the clinician has explained the procedure, its benefits, and potential risks to me. I have had the opportunity to ask questions, and all of my concerns have been addressed to my satisfaction. I understand that the results of the UV lash extensions or traditional glue-based lash extensions can vary.

Release of Liability:

I release The Abram, its employees, and representatives from any liability associated with the UV lash extensions or traditional glue-based lash extensions, except for cases of negligence or intentional misconduct.

Human Error Acknowledgment:

I understand that aesthetic treatments are performed by qualified clinicians using professional equipment and established protocols. However, I acknowledge that, as with any procedure involving human involvement, there is a possibility of unintended outcomes due to human or technical error. By signing this consent, I accept this inherent possibility and agree that The Abram and its staff shall not be held liable for minor or unintentional errors occurring during the course of treatment, provided that reasonable care and professional standards are followed.

Photographs and records:

I understand that videos and photos will be taken for medical documentation purposes and will be used only for treatment comparisons and tracking progress milestones.

Client's Initial

Receptionist's Initial

Technician's Initial

I agree that all the above information is true and accurate to the best of my knowledge

Client’s signature: