LASHEXTENSION

CONSENTFORM

APPOINTMENT TIME- 1:30

APPOINTMENT DATE- Saturday

LAST NAME- Fazil

FIRST NAME- Sama

PHONE NUMBER-
236-516-2144
ADDRESS- 7136 194B St, Surrey, Bc

INSTAGRAM @
EMAIL ADDRESS- samafazil@icloud.com

I give permission to take "before and after" pictures for adverting and marketing purpose. I
understand that these pictures can be posted on social media.

I understand there are risks associated with lash extensions.

I agree to the after - care instructions given by the technician and realize that not following these
instructions may result in damage to my natural lashes.

First time lash lifting. Frequent eye irritation, itching or watering.

I wear contacts. Resent permanent eyeliner.

Eye surgery within the last 6 months . Current use of eye medication or antibiotics
antibiotics.

I'm pregnant. Blepharoplasty.

Other medical information:

By signing this form, I approve that I understand all the information listed. I consent to this agreement
and the lash extension procedure.

CLIENT SIGNATURE: Sama Fazil DATE: 5/16/23

TECH SIGNATURE: DATE: