top of page

Medical & Allergy History:

Have you ever had an allergic reaction to eyelash extensions, tint, glue, or skincare products?
Yes
No
Do you have sensitive skin or eyes?
Yes
No
Do you wear contact lenses?
Yes
No
Do you have any eye conditions (e.g., conjunctivitis, blepharitis, styes)?
Yes
No
Are you currently taking any medication or under medical care?
Yes
No
Do you have any known allergies (latex, adhesives, etc.)?
Yes
No

PATCH TEST DECLARATION:

PATCH TEST DECLARATION
I agree to have a patch test performed at least 24–48 hours before my lash service.
I decline a patch test and understand that I may be at risk of an allergic reaction.

I acknowledge that by declining a patch test, I am fully responsible for any adverse reactions that may occur during or after the treatment. I release the salon and technician from all liability related to such reactions.

Client Signature:

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date:

Technician Signature:

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date:

Patch Test Details

Product(s) tested:

Patch Test Results (to be completed by technician)

Reaction Observed:

Client Declaration & Consent:

I confirm that:

  • The information I have provided is true and accurate.

  • I understand the purpose and procedure of the patch test.

  • I understand that allergic reactions may still occur even after a negative patch test.

  • I release the technician and salon from any liability related to allergic reactions or side effects.

Signature (type full name): 

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date:

Aftercare Advice:

• Do not wash or rub the patch test area for 24–48 hours.


• Observe for redness, swelling, itching, or irritation.


• Contact your lash technician immediately if any reaction occurs.


• Seek medical advice if necessary.

Eyelash Patch Test Form

bottom of page