EYELASH EXTENSIONS CLIENT PROFILE
NAME
DATE
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Month
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Day
Year
Date
ADDRESS
PHONE
EMAIL
example@example.com
How did you hear about us?
Instagram
Facebook
Friend
Previous Client
Other
Google
Have you ever had eyelash extensions before?
Yes
No
If yes, when?
Did you have a good experience
Do you perm or tint your eyelashes?
Yes
No
What brings you in today?
Fill
Full set
Special event
Removal of lashes
What do you want to achieve today?
Natural
Cat eye
Glamour
Fox
Doll eye
Other
Do you wear contacts?
Yes or No
Have you undergone any recent eye surgery?
Yes
No
Do you have any eye conditions or injury?
Yes
No
Please list any medication you are using
Are you allergic to latex or rubber?
Yes
No
Do you have any intolerant to chemicals, a hyper sensitivity to odours?
Yes
No
If yes, please specify
Are you Pregnant?
Yes
No
Date
/
Month
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Day
Year
Date
Signature
Please check off beside all that might apply to you :
Iron Deficiency.
Seasonal Allergies
Lumps/Cysts_
Lasik Eye Surgery.
Alopecia
Cold Sore around Eyes_
Permanent Eye Makeup
Hormonal Imbalance
Diabetes
Hypersensitive Eyes
Blepharoplasty
Asthma_
Use of Retin A or Accutane_
Anticoagulants,
I understand that there are risks associated with having artificial eyelashes applied to and/or removed from my natural lashes.
Initials
I understand that the eyelash extensions will be applied to the natural lash as determined by the technician so as not to create excessive weight on the natural eyelashes thereby preventing the health, growth and natural look of the client’s natural eyelashes.
Initial
I understand that as part of the procedure eye irritation, pain, itching discomfort and in rare cases eye infections may occur.
Initial
I understand and agree that if I experience any of these issues with my lashes I will contact my technician and have the eyelashes removed immediately and consult a physician at my own expense.
Initial
I understand that even though the technician may apply and remove the eyelash extension properly, that adhesive material may become dislodged during or after the procedure, which may irritate my eyes or require further follow up care.
Initial
I understand and agree to follow the aftercare instructions provided by my technician. Failure to follow the aftercare instructions may cause the eyelash extensions to fall out or other discomfort.
Initial
I understand in order to have the eyelash extensions applied to my eyelashes i will need to keep my eyes closed for duration of 60-180 minutes during the procedure. I also understand that i will need to be lying in a reclined position. Any medical conditions that might be aggravated by lying still for prolonged periods of time may mean that I will not be able to have the procedure performed on my eyes.
Initial
This agreement will remain in effect for this procedure and all future procedures conducted by Yem. I understand that this agreement is binding and that I have read and fully understand all information above. I represent that I am over the age of 18 years. If below 18 years of age a parent or guardian must also sign this form.
Initial
I release my technician/Stelletta Beauty from all liability associated with this procedure. There are no guarantees for the bonding time length of the eyelash extensions. Our company or salon is not responsible for any technicians errors. I understand that I have been advised to follow the aftercare protocol from my technicians so as to avoid any discomfort or adverse side effects after the procedure has been completed.
Initial
I allow Yem at Stelletta Beauty to take a before / after picture of my service - these photos may be used on our website, our Instagram or Facebook page etc.
Initial
By signing below, I verify that I have read and understand the above statements and agree to them.
Date
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Month
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Day
Year
Date
Parent or Guardian
(If under 18 years of age) Name & Signature
Signature Technician
Date
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Month
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Day
Year
Date
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