Eyelash Extension Client Intake & Consent Form
Full Name
*
First Name
Last Name
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
I release Eleven Thirteen Minks from any and all liability associated with procedure. This service will be performed will all attention to safety, sanitation, and proper application using tools and products that the technician has been trained and certified to use. The technician (along with my consent form and consultation) will decide if I am a good candidate for this service.
*
Initial
I grant permission to Eleven Thirteen Minks to use my before and after pictures for marketing or examples of my technicians work.
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Yes
No
Is this your first time having Eyelash Extensions?
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Yes
No
Do you have a severe eye illness or are you being treated for an eye injury?
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Yes
No
Do you wear contacts?
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Yes
No
Are you able to lay on your back for 2 - 3 hours to have your lashes applied?
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Yes
No
How do you usually sleep? Please note, you will loose more extensions on the side on which you sleep. Sleeping on your stomach will affect your lashes the most. It is important to refrain from sleeping on your stomach the first 2 days after your service to allow the adhesive to set properly.
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Stomach
Back
Side
Are you allergic to adhesives (glue, tapes, band aids, etc.)? This service may use adhesives tapes, glues, and gel pads that may cause an allergic reaction.
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Yes
No
I agree and understand that Eleven Thirteen Minks and my Lash Technician has no way of knowing if a client is allergic to some of the products or materials being used in any eyelash procedure, we also use sensitive eye products to ensure comfort for every client. I will seek medical care (at my own expense) and contact my lash technician immediately if any allergic reaction occurs. All of my questions were answered and I fully understand the procedure and risks.
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Initial
Thank you for giving us the time to get to know you and signing the consent form!
*
By signing below, I verify that I have read and fully understand the above statements and information I have provided on this form is truthful and accurate.
Sign Date
*
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Client Signature
*
Submit
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