LASH BAR NOLA NEW CLIENT EVALUATION FORM FOR LASH EXTENSIONS
Name
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First Name
Last Name
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about Lash Bar Nola?
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Are you allergic to Acrylate/Cyanoacrylate (Bonding Agent)?
Yes
No
Health history: Please list any allergies you have including (cosmetics/ingredients):
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Have you ever had any of these conditions?
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Please Select
NONE
Alopecia
Asthma
Back pain
Blepharitis
Cancer/chemo
Claustrophobia
Conjunctivitis
Diabetes
Dry eyes
Eating disorder
Hormonal imbalance
Intense stress
Light sensitivity
Migraines
Sensitive eyes
Stroke/TIA
Thyroid disease
Recent eye
Surgery current
Eye irritation
Possible pregnancy
Watery eyes
Any other Health conditions not listed?
Please answer each question.
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Rows
Yes
No
Do you wear contacts?
Do you wear glasses?
Do you use Rentin-A or Accutane?
Have you had facial treatments?
Do you use Lattissue or Lash Growth Products?
I understand that lash extension services have some inherent risk of irritation to the orbital eye area, including the eye itself, and could result in stinging and burning, blurry vision should the adhesive enter the eye or should an allergic reaction occur.
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I understand that some irritation, itching or burning may occur on the skin if the bonding agent comes into contact with it.
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I understand if bonding agent comes into contact with my eye, my eye will be flushed with water and I will be a assisted in seeking medical attention immediately
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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 refill appointments necessary to maintain the original look achieved by replacing the lashes that have fallen out. Most clients require a refill appointment every 2-3 weeks.
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I understand that it is imperative that I disclose all of the information requested in the Client Profile/Health History.
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I understand that the additional conditions could occur or be discovered during the procedure which could affect my ability to tolerate the procedure.
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I consent to “before and after pictures” for purpose of documentation potential advertising and promotional purposes
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I understand if I have any concerns, I will address these with my technician. I give permission to my technician to perform the lash extension procedure that we have discussed, and will hold him/her and his/her staff harmless and nameless from my ability that may result from this treatment. I have accurately answer the questions above, including all known allergy prescription‘s drugs or products I’m currently ingesting or using tropically. I understand my last extension specialist will take every precaution to minimize or eliminate negative reactions much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult the last extension specialist immediately. I agree that this constitutes for all disclosure, and that it superseded any previous verbal or written disclosure. I certify that I have read and fully understand the procedure and except the risk. I do not hold Perla Rodriguez, responsible for any of my conditions that were present,but do not disclosure at the time of this procedure, which may be affected by the treatment performed today. PLEASE PRINT YOUR NAME.
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Signature
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Submit
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