Eyelash Extension Intake Form
General Information
Name
*
First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Phone#
*
Format: (000) 000-0000.
Email
*
example@example.com
Occupation
Emergency Contact Name
Phone#
Format: (000) 000-0000.
How did you hear about us?
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Health & Safety Screening
Have you ever had an allergic or adverse reaction to eyelash extensions, lash adhesive, cyanoacrylate, tape, gel pads, or other eye-area cosmetic products?
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Yes
No
Do you have any known allergies or sensitivities to adhesives, acrylates/cyanoacrylate, latex, tape, cosmetics, or skincare products?
Yes
No
Do you currently have redness, swelling, itching, irritation, excessive watering, discharge, pain, or unusual sensitivity in or around either eye?
Yes
No
Do you currently have, or have you recently had, pink eye/conjunctivitis, a stye, blepharitis, or another eye infection?
Yes
No
Do you currently have broken or irritated skin, cuts, dermatitis, eczema, psoriasis, or another skin condition around the eyes?
Yes
No
Have you recently had eye surgery, LASIK, permanent eyeliner, cosmetic tattooing, or another procedure involving the eye area?
Yes
No
If yes, when?
Do you have extremely sensitive or excessively watery eyes?
Yes
No
Do you wear contact lenses? If so, you must remove them before your appointment.
Yes
No
Are you currently using a prescription lash-growth medication or lash serum?
Yes
No
If yes, which one?
Are your natural lashes currently damaged, brittle, unusually thin, breaking, or shedding excessively?
Yes
No
Have you experienced unusual or excessive natural lash loss following eyelash extensions in the past?
Yes
No
Have you had eyelash extensions applied by another provider that are currently still on your lashes?
Yes
No
Have you ever experienced swelling, itching, redness, burning, or another reaction within 24–72 hours after receiving eyelash extensions?
Yes
No
Is there anything regarding your eyes, lashes, skin, allergies, medications, health, or previous reactions that your lash artist should know before performing your service?
Yes
No
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Eyelash Extension Consent Form
I acknowledge:
*
I understand that eyelash extensions are individually attached to my natural eyelashes using professional lash adhesiveand that the service is performed in close proximity to my eyes.
I understand that possible reactions may include redness, itching, irritation, watering, swelling, sensitivity, allergic reaction, or other eye-area irritation. I understand that an allergic reaction or sensitivity can develop even if I have previously worn eyelash extensions without a reaction.
I understand that eyelash extensions naturally shed along with my natural lash growth cycle and that regular fills are necessary to maintain their appearance.
I understand that retention varies based on my natural lash cycle, skin type, lifestyle, medications, hormones, skincare products, makeup, cleansing habits, sleeping habits, and aftercare. Exact retention or longevity cannot be guaranteed.
I understand that rubbing, pulling, picking, or attempting to remove my extensions myself may damage or prematurely remove my natural lashes.
I understand that improper aftercare, inadequate cleansing, excessive product buildup, or failure to maintain proper lash hygiene may contribute to irritation, buildup, poor retention, or other complications.
I understand that my lash artist will select the length, diameter, weight, and amount of extensions appropriate for the condition and strength of my natural lashes and may decline a requested style that could compromise my natural lashes.
I understand that my natural lashes continuously grow, shed, and replace themselves, and some natural lash shedding while wearing extensions is normal.
I agree to immediately inform my lash artist if I experience burning, stinging, pain, excessive watering, or significant discomfort during the service.
I understand that my lash artist may modify, discontinue, postpone, or refuse the service if my eyes, surrounding skin, or natural lashes appear unsuitable or compromised.
I confirm that I have disclosed relevant allergies, sensitivities, medications, eye conditions, previous reactions, and recent treatments.
I agree to follow the recommended eyelash extension cleansing, maintenance, and aftercare instructions and voluntarily consent to receiving eyelash extensions.
By signing below, I acknowledge there is a no-refund policy in place. By paying for my service at the completion, I am acknowledging that I am satisfied with my services provided and credit card disputes will then be considered frivolous.
I hereby grant and authorize Lancaster’s Luxe Lashes the right to take, edit, alter, copy, exhibit. publish, distribute and make use of any and all pictures. video, and/or audio is taken of me to be used in and/or for any lawful promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, press kits, websites, social networking sites, and other print or digital communications without payment or any other consideration. This authorization extends to all languages, media, formats, and markets now known or later discovered. I waive the right to inspect or approve the finished product wherein my likeness appears, including a written or electronic copy. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I hereby hold harmless and release Lancaster’s Luxe Lashes from all liability, petitions. and causes of action which I. my heirs. representatives. executors. or any other persons may make while acting on my behalf or on behalf of my estate.
I agree to the following eyelash extension follow-up and maintenance instructions:
No oil, wax, or petroleum - based products on the entire face and hair
No mascara or eyeliner on tops or bottoms
No tinting or perming of eyelash extensions
No pulling or rubbing of the eyelash extensions
Should any kind of eye drops or contacts be necessary extra care should be taken to prevent pulling on the eyelash extensions
Use of a satin pillowcase and eye mask is necessary daily
Washing the lashes is mandatory 1-2x a day, and additionally after tears, sweat, chlorine or salt water
Fill appointments are recommended every 2 weeks and required a max of every 21 days
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Take Photo
*
Name Printed
*
Signature
*
Submit
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