Lash Extensions Intake Form
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthday
*
/
Month
/
Day
Year
Date
How did you find Kempt Esthetics?
*
Were you referred by anyone? If so, who?
Do you give consent to photos taken during your service and posted on social media for marketing purposes?
*
YES
NO
Have you had lash extensions before?
*
YES
NO
Have you ever had a reaction from a lash extension service?
*
If yes, explain you reaction.
Have you had a lash lift in the last 6 months?
*
NO
YES
I understand that touch-up appointments may be necessary as soon as two weeks after the application. I acknowledge that if more than 40% of my extensions are gone at my two-week touch up, there will be an extra charge.
*
YES
Do you wear contact lenses?
*
NO
YES (if yes, it is recommended to remove before service)
Have you had any eye issues in the last 6 weeks?
*
NO
YES
Are you pregnant?
*
NO
YES
HOW TO CARE FOR YOUR EXTENSIONS... check all to indicate you understand
*
no mascara
no oil based products around the eye area
no water contact in 24 hours after application
no tinting or perming with extensions on
no pulling or rubbing
wash eyelash extensions AT LEAST once a day
Medical History. Check all that apply
*
Epilepsy
Strokes
Dry eyes or Sjorgen Syndrome
Rapid hair loss
Other
Please list any allergies or sensitivities:
*
Have you had recent (within 6 months) face, neck, shoulder surgery?
*
NO
YES
I understand this service takes about 2-3 hours.
*
YES
I understand that in rare occasions there are risks associated with having artificial eyelashes. If an allergic reaction occurs, I will contact the lash technician that preformed this procedure and it may be beneficial for a removal. No refunds will be issued.
*
YES
I agree to come to the appointment with clean eyelids, lash line, free from oils and lotions. (if not, there will be a $15 charge)
*
YES
I understand if I want lash extensions consistently I must prebook my appointments and within 2-3 weeks. If more than 40% of my extensions are gone at the time of my appointment, there will be an extra charge.
*
YES
I understand, acknowledge and agree that I have provided all relevant information regarding my medical history and health conditions. I agree that the lash artist is not responsible for any doctor co-pays or bills that may occur after the procedure. I am over the age of 18 years old. I have come to this location at my own free will. I understand this consent agreement is legal and binding and I will hold Kyana Bailey and Kempt Esthetics harmless from any liability that may result from this treatment. By signing below, I agree to the terms listed above.
Submit
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