Intake & Consent Form

Your safety and comfort come first! Please fill out this form before your lash appointment so we can give you the prettiest, safest results possible.

Full Name

Phone Number

Email

Instagram Handle

Preferred Contact Method

Text

Instagram DM

How did you hear about prettylashesbyjill?

Birthday (you get 15% off when you book on your bday month)

Check all that apply

Eye allergies (to glue, makeup, latex, etc.)

Skin sensitivities or eczema around eyes

Chronic eye conditions (styes, blepharitis, pink eye, etc.)

Recent eye surgery or LASIK (in last 6 months)

Pregnant or nursing

Taking medications that affect hair growth or skin sensitivity

Worn lash extensions before

Had allergic reaction to lash extensions before

Which lash set are you booking?

Do you currently have lash extensions on?

Yes (Please note: a $15 removal fee will be required since it is a foreign set.)

I consent to before and after pictures for the purpose of documentation, potential advertising, and purposes

Yes, internal documentation only (not shared)

Yes, marketing use allowed if identity hidden

Yes, full marketing use permitted

No, I do not consent to any photo use

By checking all the following boxes, you confirm you have read and agree to each statement:

I understand that there are risks associated with having artificial eyelashes applied to and/or removed from my natural lashes.

I understand that as part of the procedure, eye irritation, pain, itching, discomfort, stinging, burning, and in rare cases eye infection may occur.

I understand and agree that if I experience any of these issues with my lashes, I will contact my technician and have the eyelash extensions removed immediately and consult a physician at my own expense.

I understand that even though the technician may apply and remove the eyelash extensions properly, adhesive material may become dislodged during or after the procedure, which may irritate my eyes or require further follow-up care.

I understand and agree to follow the aftercare instructions provided by my technician. Failure to follow the aftercare instructions may cause the eyelash extensions to fall out.

I understand that in order to have the eyelash extensions applied to my eyelashes, I will need to keep my eyes closed for a duration of 60–180 minutes during the procedure. I also understand that I will need to be lying in a reclined position. Any medical conditions that might be aggravated by lying still for a prolonged period of time may mean that I will not be able to have the procedure performed on my eyes.

This agreement will remain in effect for this procedure and all future procedures conducted by my technician. I understand that this agreement is binding and that I have read and fully understand all information above.

I release my technician from all liability associated with this procedure. There are no guarantees for the bonding time length of the eyelash extensions. My technician is not responsible for any technician errors. I understand that I have been advised to follow the aftercare protocol from my technician so as to avoid any discomfort or adverse side effects after the procedure has been completed.

Minor Check

I am 18 years or order

I am under 18

Date

Emergency Contact Name

Emergency Contact Phone Number

By signing below, I verify that all the information I’ve provided is true, and I have read, understood, and agree to the statements above.

Signature

Date

Please confirm that the $15 non-refundable deposit has been sent to jillianmanguba24@gmail.com

I have sent it!

Please upload a screenshot of your e-transfer confirmation.

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