Consultation Form
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Phone Number
*
Please enter a valid phone number.
Date of Birth
*
-
Day
-
Month
Year
Please tick if you have any of the following contraidications
Claustraphobia
Epilepsy
Diabetes
Eczema / Psoriasis
Hypersensitive Skin
Recent Botox/Fillers
Styes
Pregnancy
Conjunctivitis
Blepharitis
Wearing contact lenses
Reaction to patch test
Other
Please list any physical health conditions that your therapist should be aware of (if none please write none):
Please list any medication taken regularly and any specific medication/pain killers taken today (if none please write none):
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Treatment Specific
Please only tick boxes for the treatment you are receiving
Eyelash Extensions
Brow Lamination
Waxing
Lash Lift
Lash or Brow Tinting
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Next
Date
*
-
Day
-
Month
Year
Date
Signature
*
Submit
Should be Empty: