Consult & Consent

Name

First NameLast Name
Name*

First NameLast Name
BIRTHDAY *

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
What is the best way to contact you?*

TextEmailPhone call
How did you hear about LK Studio?
Instagram Referral
Have you had lash extensions before?*

YesNo
Do you have any allergies?*

YesNo
If yes please list.
Have you ever had an allergic reaction to adhesives containing cyanoacrylate?*

YesNoIm not sure
Any sensitivities to medical tape, creams, serums or any other topical products?*

YesNo
If yes please list.
Do you suffer from any of the following? Please check all that apply.*

Watery eyesLight sensitivityActive eye infectionblepharitisDiabetesCancerHormone imbalanceAlopeciaTrichotillomaniaBack painNeck painNone
Certain medications and supplements affect hair growth and may lead to poor retention. Are you currently taking any medications, vitamins or any other dietary supplements?*

YesNo
If yes please list.
Do you wear contacts or glasses?*

YesNo
Do you have any conditions that affect the eye? (Glaucoma, dry eyes etc.)*

YesNo
If yes please list.
Do you use any eye drops or eye ointments?*

YesNo
If yes please list.
Have you ever experienced issues with lash loss?*

YesNo
If yes please explain.
Are you currently using a lash serum?*

YesNo
Please list all the face products you use in a day. (Make up, cleansers, toners, creams, serums, oils etc.)*
How would you describe your skin?*

DryOilyCombination
If you currently have extensions. How often do you wash them?
Do you participate in any activities that cause excessive sweating?*

YesNo
Are you a swimmer?*

YesNo
How do you sleep at night?*

BackSideStomach
What do you do for work?*
Iblanks* Agree to have eyelash extensions applied to my natural lashes and/or removed and retouched. By signing this agreement, I consent to the placement and/or removal of eyelash extensions by Lash kings Studio. I understand that in rare occasions there are risks associated with having artificial eyelash extensions applied to or removed from my natural lashes. I further understand that in rare cases as a part of the procedure, irritation and discomfort could occur. I agree that if I experience any irritation or discomfort with my lashes, that I will contact Lash King Studio and it may be beneficial to have the eyelash extensions removed.
Date

MonthDayYear
Date
Signature*
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