Lash Extension Intake Form

Eyelash Extension Intake Form
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Please check any of the following conditions that apply to you.

Glycerin AllergyLatex AllergyUse of drugs that cause hair lossIron deficiencyPregnancyDry eyesSensitive eyesWatery eyesAlopeciaAntibioticsClaustrophobiaExtreme stressRecent Lasik surgeryChemo within the last 6 monthsHormonal imbalance
Any other condition not listed?
Please list any eye medication or drops you are currently using:
Are you applying extensions for daily wear or special occasion?

Daily wearSpecial occasion
Is this your first time getting lash extensions?

YesNo
If no where and when did you last receive lash extensions?
Which side do you usually sleep on?

LeftRightBackStomach
Do you wear glasses or conacts?

GlassesContactsBothNone
I consent to before & after pictures for the use of potential advertising & promotional purposes?

YesNo
Although every precaution will be taken to ensure your safety and well being before, during and after your lash extension application, please be aware of the following information and possible risks. I understand that some irritation, itching or burning may occur on the skin if the bonding agent comes into contact with fumes from adhesive. I understand that this is a semi-permanent procedure, as my natural lashes will continue to grow and fall out normally, making touch-up or additional appointments necessary to maintain the original look achieved by replacing the lashes that have fallen out. Most clients require a "fill" appointment every 2-3 weeks. I understand that while every attempt will be made to provide me with the length and fullness I have chosen, my final result may not be what I initially envisioned due to my eye shape, quantity of my lashes, etc. I understand that it is imperative that I disclose all of the information requested in the Client Profile/Health History. I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications. I understand that additional conditions could occur or be discovered during the procedure which could affect my ability to tolerate the procedure. I consent to “before and after” photographs for the purpose of documentation.
Acknowledgement and Waiver I am over 18 years of age and consent to the agreement and to treatment or have a parent with me that consents to this service. This agreement will remain in effect for this procedure and all future procedures conducted by my technician. I read English and understand that this consent agreement is legal and binding. I have read and fully understand all information in this agreement. I release my technician from all liability associated with this procedure, which is performed with the utmost attention to safety and proper application using tools and products that the technician has been professionally trained to use. I understand the aftercare instructions and will do my part to maintain my eyelashes. I understand that there are many factors that may affect the life of the eyelash extensions such as water and moisture contact, weather conditions, and activities involving exposure to high temperatures. By signing below, I verify that I have read and understand the above statements and agree to them.
Signature

Clear
Should be Empty:

Eyelash Extension Intake Form