Luxe Lashes and Lingerie by S. Monique
Lash Extension Waiver
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Date of birth
*
/
Month
/
Day
Year
Date
Emergency Contact name
*
Emergency contact Phone
*
DO YOU WEAR CONTACT LENSES?
*
YES
NO
DO YOU HAVE OR ARE YOU BEING TREATED FOR ANY EYE ILLNESS OR INJURY?
*
YES
NO
DO YOU HAVE A RESPIRATORY PROBLEMS?
*
YES
NO
Do you have any eye sensitivities? (Itchy eyes, hayfever etc)
*
Do you have any allergies to adhesives, tape, eye pads, or synthetics?
*
If yes, please state
*
Any medical information we should know about?
*
By signing, I confirm that I have read and understood all the terms and conditions of this service.
*
Submit
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