Treatment Consent Form

Welcome to Ash Esthetics! To ensure the best and safest experience for your lash extension treatment, please complete this consent form prior to your appointment. This form helps us understand your medical history, any potential allergies, and your agreement to the treatment process.

Client Information & Consent

This consent form is a crucial step before your lash extension treatment at Ash Esthetics. It allows us to gather a history of any medical issues or allergies you may have. By filling out this form, you provide consent to treat you and apply lash extensions, and agree to our aftercare guidelines and liability waiver.

Medical History & Allergies

Please disclose any relevant medical conditions, past surgeries, current medications, or known allergies (especially to adhesives, latex, or acrylates) that may affect your treatment.

Pros and Cons of Eyelash Extensions

Pros: Enhanced appearance, fuller and longer lashes, reduced need for mascara, time-saving in daily routine.

Cons: Potential for allergic reactions, irritation, temporary shedding, requires proper maintenance and aftercare, risk of damage to natural lashes if not applied or maintained correctly.

Procedure Consent

I understand the procedure for applying eyelash extensions and agree to have them applied by the technician at Ash Esthetics. I have had the opportunity to ask questions regarding the procedure, and all my questions have been answered to my satisfaction.

Liability Waiver

I acknowledge that while Ash Esthetics takes all necessary precautions, there is a possibility of adverse reactions. I agree to release Ash Esthetics and its staff from any and all liability associated with any reaction or complication that may arise from the lash extension services.

Aftercare Agreement

I understand and agree to follow the provided aftercare instructions to ensure the longevity and health of my lash extensions and natural lashes.

Negative Reaction Protocol

In case of a negative reaction, I understand the importance of contacting Ash Esthetics immediately and seeking professional medical advice if necessary.

Client Signature

_________________________ (Signature)

_________________________ (Printed Name)

_________________________ (Date)

Client Contact Information

Full Name: [[Client Name]]

Phone Number: [[phonenumber]]

Email: [[email]]

Confirmation of Understanding

I confirm that I have read and understood the information provided regarding the pros and cons of eyelash extensions, the procedure, the aftercare requirements, and the liability waiver. I understand what to do in case of a negative reaction.

Patch Test Information (If Applicable)

If a patch test was conducted prior to this appointment, please note the results here: [[Patch Test Results]]

Emergency Contact Information

Name: [[Emergency Contact Name]]

Phone Number: [[Emergency Contact Phone Number]]

Ready for Beautiful Lashes?

Complete this form to book your lash extension appointment and experience the magic of Ash Esthetics in Chelmsford, Massachusetts.