Client Evaluation Form for Lash Extensions

Name

Address

Street Address Line 2

City State

Zip

Home/Cell Phone

Email

example@example.com

How should we contact you? Home/Cell Phone:

Home/Cell Phone

Text

Email

example@example.com

How did you hear of us?

Health History Please list any allergies you have (including cosmetics/ingredients)

Are you allergic to Acrylate/Cyanoacrylate (bonding agent)? Yes / No / Don't Know

Yes

No

Have you ever had a reaction to adhesive tape, topical creams, nail adhesives, or other topical products? Yes/No Do you have any eye disease, condition or injury that has affected your hair/lash growth or loss? Yes/No Please list all current medications you are taking (including over-the-counter herbs, vitamins and supplements):

Have you ever had any of these conditions? (Please circle)

Any other health condition not listed

These questions are relevant to your hair growth, and overall hair health. Please answer as fully as possible.

Do you use Retin-A or Accutane?

Have you had facial treatments?

Have you had Botox or injections?

Do you use Latisse or lash growth products?

Which side do you most often sleep on?Right

Left Stomach

Right

Back

How fast do you feel your hair grows?

Fast Slow Normal Rate

Is there anything else we should know about?

Although every precaution will be taken to ensure your safety and wellbeing before, during and after your lash extension application, please be aware of the following information and possible risks. Please initial:

result in stinging and burning, blurry should the adhesive enter the eye or should an allergic reaction occur.

seeking medical attention immediately.

up or "fill" appointments necessary to maintain the original look achieved by replacing the lashes that have fallen out. Most clients require a fill appointment every 2-3 weeks.

I understand that lash extension services have some inherent risk of irritation to the orbital eye area, including the eye itself, and could I understand that some irritation, itching or burning may occur on the skin if the bonding agent comes into contact with it. I understand that if the bonding agent comes into contact with my eye, my eye will be flushed with water and I will be assisted in I understand that this is a semi-permanent procedure, as my natural lashes will continue to grow and fall out normally, making touch I understand that it is imperative that I disclose all of the information requested in the Client Profile/Health History.

I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products medications.

I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products

procedure.

I understand that additional conditions could occur or be discovered during the procedure which could affect my ability to tolerate the

consent to "before and after" pictures for the purpose of documentation, potential advertising and promotional purposes.

I consent to "before and after" pictures for the purpose of documentation, potential advertising and promotional purposes.

I understand that if I have any concerns, I will address these with my technician. I give permission to my technician to perform the lash extension procedure we have discussed, and will hold him/her and his/her staff harmless and nameless from any liability that may result from this treatment. I have accurately answered the questions above, including all known allergies, prescription drugs, or products I am currently ingesting or using topically. I understand my lash extension specialist will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult the lash extension specialist immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the lash extension specialist, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today.

Client Name (Printed)

Client Name (Signature)

Clear

Date

Lash extension specialist

Date