Eyelash Extensions Intake Form

Eyelash Extensions Intake Form

Luxe Skin Studio
Client Information
Client Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*

Area CodePhone Number
Date of Birth*

MonthDayYear
Date
Occupation*
How did you hear about us?*
Medical / History Data
YesNo
Did you have any allergic reactions? If yes, what?
Do you have any seasonal allergies? If yes, please list them below:
YesNo
YesNo
Do you have any additional information you would like to let your Esthetician know before your scheduled appointment? Do you have a desired look you would like to achieve?
Please read below the aftercare instructions for taking care of your eyelash extensions.
- No oil based products around the eye area
- No steam within 24 hours of getting eyelash extensions applied (be cautious about a hot shower)
- No use of mascara
- No tugging or pulling on eyelash extensions as this can damage to your natural lashes
- No use of cotton balls or Q tips around eye area
- Gently comb through eyelash extensions daily with a clean mascara wand
- Clean lashes daily with appropriate lash cleanser and brush
Authorization
I have completed this form to the best of my ability and knowledge and agree to inform the esthetician of any changes in the above information. I understand that withholding information or providing misinformation may result in contraindications or irritation to the skin from treatment received. The treatments I receive here at Luxe Skin Studio are voluntary and I release this skin care professional from liability and assume full responsibility thereof.
Client Signature*

Clear
If under 18, Parent/Guardian Name

First NameLast Name
Parent/Guardian Signature

Clear
Should be Empty:

Eyelash Extensions Intake Form

Client Information

Medical / History Data

Authorization