Eyelash Extension

EYELASH EXTENSIONS CONSULT/CONSENT FORM
Name*

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Address*

Street Address

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Phone Number*

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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?*

YesNo
Do you have frequent eye irritation, itching, or watery eyes?*

YesNo
Have you had eye surgery in the last six months?*

YesNo
PLEASE NOTE: Eyelash extensions require medical tape and adhesives that may contain latex or acrylic
Are you allergic to latex?*

YesNoI don’t know
Are you allergic to acrylic?*

YesNoI don’t know
RELATING TO THE EYE:*

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 ( a by-product released in cyanoacrylate adhesives)Retinoids used to treat acne and skin problems (such as accutane or retin-a)OtherNone
RELATING TO EYELASHES:*

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 agents used in cancer treatment, anticoagulants (blood thinners), beta blockers (used to control blood pressure)OtherNone
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