Client Intake Form
Lash Extensions
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please check any of the following conditions that apply to you.
*
Glycerin Allergy
Latex Allergy
Alopecia
Watery eyes
Pregnancy
Hormonal imbalance
Iron deficiency
Sensitive eyes
None
Please list any other conditions that were not listed
Is this your first time getting eyelash extensions?
*
Yes
No
Are you 18 years of age or older?
*
Yes
No
Do you wear glasses or contacts?
*
Yes
No
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. Please check all boxes below that you have fully read and agreed to all terms.
*
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, potential advertising and promotional purposes.
Acknowledgment and Waiver agreement *Please check all boxes below that you fully read and agreed to all terms.
*
I am/over 18 years of age and consent to the agreement and treatment or am/have a parent that consents to this service. This agreement will remain in effect for this procedure and all future procedures conducted by my technician. I have read 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
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
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