Eyelash Extension

Kiss N Makeup Boutique

Lash Extension /Lash Lift form
Client Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Occasionally we may send out emails or newsletters about upcoming discounts, promotions, contests, company information etc. If you would like to be added to the subscriber list please check “Yes” below. If you would like to opt out please check “No”.
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Eyelash extensions require medical tape and adhesives that may contain acrylic or latex.
YesNo
YesNo
PLEASE CHECK ANY OF THE FOLLOWING THAT MAY APPLY TO YOU:
Eye surgeryEye illness or injuryDry eyesSeasonal allergiesEye InfectionPermanent eye make-upBlepharoplastyBlepharitis (inflammation of eyelids)Allergies to cyanoacrylate adhesives (i.e. surgical glue, nail glue, crazy glue)Hypersensitivity to formaldehyde ( aby-product released in cyanoacrylateadhesives)Retinoids used to treat acne and skin problems (such as accutane or retin a)
Hormone imbalanceRecent severe illness or injuryPregnancy or recent childbirthNew prescriptions or recently prescribed oral contraceptivesTypes of medical conditions that may contribute to hair and eyelashloss: hyperthyroidism or hypothyroidism, alopecia areata, lupus, diabetesVitamin and mineral deficiencies that may contribute to hair and eyelash loss:A, F, B, Selenium, Zinc, IronTrichotillomania (hair pulling disorder)Medications that may contribute to hair or eyelash loss: chemotherapeutic agentsused in cancer treatment, Anticoagulants(blood thinners), beta blockers (used tocontrol blood pressure)
Other Medical Information
Cancellation Policy

Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in our day that could have been filled by another client. As such, we require 24 hours notice for any cancellations or changes to your appointment. Clients that provide less than 24 hours notice or miss their appointment will be charged a cancellation fee.
I Agree to the Cancellation Policy*
Initial
Care and Maintenance

I agree to follow the care and maintenance instructions provided by the eyelash extension artist for the use and care of my eyelash extensions, and that if any follow up care is required due to my own mistake or negligence, or failure to follow these instructions, this will be at my own expense and risk. I understand that if I do any of the following, it may result in damage to my eyelash extensions or may cause my lashes to fall off prematurely. Knowing this I agree to follow these tips for best results:
- I will avoid oil based eye products, as these will loosen the bond of my eyelash extensions. 
- If I experience any itching or irritation, I agree to contact a medical doctor immediately and the eyelash extension artist to have the eyelash extensions removed. 
- I agree to avoid using waterproof mascara and to not use an eyelash curler, perm, or tint my eyelash extensions. 
- I agree to not pick, pull or rub my eyelash extensions.
- I understand that I should not attempt to remove my lash extensions on my own or with any product, but that the procedure requires that my eyelash extensions be professionally removed.
- I understand that if I pick, pull on, or rub my eyelash extensions it may result in the premature temporary and permanent loss of my artificial and natural eyelashes.
I Agree to the Care and Maintenance Terms*
Initial
No Known Medical Conditions / Informed Consent

I have read and completed the Eyelash Extension Intake Form in its entirety and in truth. I acknowledge that I have been advised of the potential harmful or negative side effects (such as the premature shedding of my eyelash) that the lash extension procedure or removal may cause to those who have specific medical or skin conditions. I understand that the adhesives and adhesive remover are a skin, eye and mucus membrane irritant and that in rare cases persons may be allergic or have hypersensitivity to synthetics, cyanoacrylate or formaldehyde, which in small amount may be present in the adhesive. I understand that the procedure requires that I lay still for up to 2 hours or longer with my eyes shut, and that if I wear contacts, I must remove my contact lenses for the duration of the lash extension application or removal. I further state that I have no known medical condition that might be aggravated by the procedure or any medical condition that would prevent me from complying with or heeding to the eyelash extension artist's instructions or these warnings.
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Kiss N Makeup Boutique