Eyelash Extension

EYELASH EXTENSIONS CONSULT/CONSENT FORM
Name *

First Name Last Name
Address *

Street Address

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Phone Number *

Area Code Phone Number
Email *
example@example.com
Occasionally Indigo Salon and Day Spa may send out emails or texts 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”.
Please select your choice below *

YES! Sign me up! No, Thank you
Have you had eyelash extensions applied before ? If yes, why did you remove them?
If yes, please provide details
Do you wear glasses? *

Yes No
Do you have frequent eye irritation, itching, or watery eyes? *

Yes No
Have you had eye surgery in the last six months? *

Yes No
PLEASE NOTE: Eyelash extensions require medical tape and adhesives that may contain latex or acrylic
Are you allergic to latex? *

Yes No I don’t know
Are you allergic to acrylic? *

Yes No I don’t know
RELATING TO THE EYE: *

Eye surgery Eye illness or injury Dry eyes Seasonal allergies Eye Infection Permanent eye make-up Blepharoplasty Blepharitis (inflammation of eyelids) Allergies to cyanoacrylate adhesives (i.e. surgical glue, nail glue, crazy glue) Hypersensitivity to formaldehyde ( a by-product released in cyanoacrylate adhesives) Retinoids used to treat acne and skin problems (such as accutane or retin-a) Other None
RELATING TO EYELASHES: *

Hormone imbalance Recent severe illness or injury Pregnancy or recent childbirth New prescriptions or recently prescribed oral contraceptives Types of medical conditions that may contribute to hair and eyelashloss: hyperthyroidism or hypothyroidism, alopecia areata, lupus, diabetes Vitamin and mineral deficiencies that may contribute to hair and eyelash loss: A, F, B, Selenium, Zinc, Iron Trichotillomania (hair pulling disorder) Medications that may contribute to hair or eyelash loss: chemotherapeutic agents used in cancer treatment, anticoagulants (blood thinners), beta blockers (used to control blood pressure) Other None
Other medical information
You must call or email Indigo Salon and Day Spa 48 hours prior to your scheduled appointment to cancel. Failure to cancel within 48 hours or be present at the time of your scheduled appointment may result in a 50% charge of your session *

I agree to the cancellation terms above
Date *

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Date
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EYELASH EXTENSIONS CONSULT/CONSENT FORM