Lash Extensions:
Client Health History
Today's Date
-
Month
-
Day
Year
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
How should we contact you?
Phone
Email
Emergency Contact
*
First + Last Name
Relationship to You
Phone Number
How did you hear about us?
*
Have you lash extensions before?
Yes
No
If yes, where have you had lashes applied?
What brand was applied?
Was it applied for a special event or daily wear?
Special Event
Daily Wear
Please indicate if you have worn any of the following lash types in the last 60 days
Individual
Strip
Clusters
Other
Do you CURL your lashes?
Yes
No
Do you PERM your lashes?
Yes
No
Do you TINT your lashes?
Yes
No
Do you use lash growth serum?
Yes
No
Do you wear contacts?
Yes
No
Have you had permanent eye liner applied in the last 30 days?
Yes
No
Have you had Blepharoplasty (Eye Lift Surgery) OR Lasik in the last 90 days?
Yes
No
Do you have frequent eye irritation, watering, and/or itching
Yes
No
Have you had an allergic reaction to Arcylate/cyanoarcylate, adhesive tape, or topical collagen?
Yes
No
Please check any and all that apply to you
Anxiety/Stress
Claustrophobia
Hormonal Imbalance
Migraines
Recent High Fever/Illness
Glaucoma
Back Pain
Dry Eye
Diabetes
Eye Injury
Iron Deficiency
Oral Contraceptives
Thyroid Disease
Herpes
Chemotherapy
Eating Disorders
Major Surgery
Pregnant or Nursing
Asthma
Seasonal allergies
Impetigo
Please list any eye drops you are currently using:
Please list any medications you are currently taking (prescribed, over-the-counter, herbs, vitamins, and supplements):
I understand a $10 surcharge will be added if I am receiving a foreign fill (meaning I did not receive my original set from Duo Tones Salon Company). We cannot guarantee our work on top of someone else's work.
*
Please Initial
Signature
Submit
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