Lash Extensions Consent & Aftercare Record

📍 BeautyTherapistForms.co.uk 🇬🇧 England & Wales Version 1.0 — 2025

1. Client Details

Full Name
Date of Birth
Contact Number
Email Address
Therapist Name
Treatment Date
Previous Lash Extensions? ☐ Yes    ☐ No    If yes, when:

2. Medical History & Contraindications

Complete this section honestly. Lash extension adhesive contains cyanoacrylate — allergic reactions, while rare, can be severe. Failure to disclose known sensitivities may result in a serious adverse reaction.

Please tick any that apply to you:

Eye conditions: current conjunctivitis, stye, or blepharitis — DEFER until fully resolved.
Contact lens wearer — remove lenses before treatment; do not reinsert for 24 hours.
Alopecia (including alopecia areata) — treatment possible; reduced retention expected; discuss with therapist.
Currently undergoing chemotherapy — GP clearance required before treatment.
Thyroid medication (levothyroxine, carbimazole) — note: may affect lash growth and retention.
Skin conditions around the eye area (eczema, psoriasis) — assess prior to treatment.
Previous adverse reaction to lash adhesive or remover — patch test required 48 hours before proceeding.
Hypersensitive skin or known cyanoacrylate sensitivity — do not proceed without medical advice.
None of the above apply.

Any other conditions, medications, or allergies relevant to this treatment:

3. Patch Test Protocol

HABIA guidance and most insurance bodies require a patch test 24–48 hours before first lash application and after any break of 12+ weeks. A signed patch test record is required before treatment proceeds. Where a client declines a patch test, this must be recorded in writing and may void the therapist's insurance cover.
Test Date Adhesive Brand Used Test Location Result Therapist Initials Client Initials
      ☐ Clear
☐ Mild
☐ Reaction		    
      ☐ Clear
☐ Mild
☐ Reaction		    

4. Treatment Record

Field Details Field Details
Application Style ☐ Classic   ☐ Hybrid   ☐ Volume   ☐ Mega Volume Adhesive Brand
Curl Type ☐ J   ☐ B   ☐ C   ☐ CC   ☐ D Application Time
Length (mm) Infill Date
Thickness (mm) Removal Date

5. Aftercare Instructions

To protect your lashes and avoid reactions, follow these aftercare instructions:
  • No steam, swimming, or excessive moisture for 24–48 hours after application
  • Use oil-free products around the eye area — oil breaks down adhesive
  • Do not rub, pick, or pull lashes
  • Brush daily with a clean spoolie
  • Avoid sleeping face-down
  • Return for infills every 2–3 weeks
  • Contact your therapist immediately if you experience redness, swelling, or irritation

6. Professional Note

This form meets HABIA (Hair and Beauty Industry Authority) recommended documentation standards. Retain for a minimum of 3 years from the date of the last treatment, or until the client's last treatment date, whichever is later. In the event of an adverse reaction, preserve all treatment records and adhesive batch information and contact your insurance provider promptly.

7. Liability Limitation

The therapist is not liable for adverse reactions arising from:

In the event of a reaction, contact your therapist immediately and, if severe, seek medical attention. Keep the adhesive batch information available for any medical consultation.

8. Declaration & Signatures

I confirm that the information provided above is accurate and complete to the best of my knowledge. I consent to the lash extension treatment detailed in this form. I have received and understood the aftercare instructions and accept responsibility for following them. I understand that failure to disclose a relevant medical condition or sensitivity may affect the safety of my treatment and the validity of any insurance claim.

Client

Signature
Date

Therapist

Signature
Date