Client Intake Form 2024

CLIENT INTAKE FORM

Please complete the following form prior to your upcoming appointment. You only need to complete this once per year.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Birthdate *

MonthDayYear
Date
CLIENT HISTORY

Lash Services, Body Waxing & Brows
Please upload a photo of your natural eyebrows/lashes in good lighting and without any makeup. This will help us better prepare for your visit.

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Have you ever had lash extensions in the past? **

YesNo
Have you ever had a negative reaction to lash extensions or lash adhesive in the past? **

YesNo
Are you currently under the care of a physician, dermatologist or opthamologist?*

YesNo
If "yes", please explain:
Do you wear contacts? (If so, please remove contacts prior to lash services)*

YesNo
Do any of the following medical conditions or treatments apply to you? **

BlepharitisCancer and/or Cancer treatmentClaustrophobiaCold soresConjunctivitis/Pink EyeCurrent eye irritationDiabetesDry Eye SyndromeEczemaFrequent swimming in chemically treated poolsHerpesHIV/AIDSHormonal ImbalanceHypersensitivity to gluesLasik eye surgeryLight sensitivityLupusMigraineOcular RosaceaPermanent eye makeupPsoriasisRosaceaSeizure DisorderSensitive EyesSkin disease/ Skin lesionsStrokeThyroid ImbalanceTrichotillomaniaRecent eye surgeryMedications that can cause temporary hair lossNONE OF THE ABOVE
Do you have any other health problems or medical conditions?*

YesNo
If "yes" please explain:
Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours?*

YesNo
Are you using Retin-a, Renova or Accutane (an oral form of Retin-a)?*

YesNo
Are you using any other skin thinning products and/or drugs? (If you are, waxing is not recommended. Please opt for threading to avoid any damage to your skin)*

YesNo
Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?*

YesNo
Do you use a tanning bed?*

YesNo
What medications or over the counter drugs are you currently taking?*

Birth control pillsHormonesAntibioticsSteroidsVitamins/herbsNONE OF THE ABOVE
Please list all current medications you are taking (including OTC, supplements and vitamins):
Have you recently had any eye surgery, eye infections or eye injuries? **

YesNo
Are you allergic to any cosmetics, skin care products, topical creams, topical products or related products or ingredient? **

YesNo
Are you allergic to Acrylate/Cyanocarylate (bonding agent)?*

YesNoUnsure
Do you have any allergies that affect your eyes, skin, digestive or respiratory system? **

YesNo
Please list all known allergies:
Do you use Latisse or any other lash growth product? **

YesNo
Which side do you typically sleep on? **

LeftRightBackStomach
How fast do you feel your hair grows? **

FastNormalSlow
Do you workout heavily, sweat excessively, swim or use saunas regularly? **

YesNo
Are you pregnant or nursing? **

YesNo
If you are pregnant, do you understand that some individuals experience allergic reactions to the eyelash extension process and that some medications or treatments may not be available to you as a pregnant woman, should you experience an allergic reaction to the eyelash extension process?*
Initial
When is your next menstrual cycle due to begin? (Always allow five days for menstrual cycle. Because of water retention and for your own personal comfort, you should avoid hair removal two days before your cycle isdue and two days after it is completed.)*
Initial
Do you form thick or raised scars from cuts or burns?*

YesNo
I voluntarily and honestly state that I have no known medical condition that might be aggravated by the service(s) or any medical condition that would prevent me from complying with or following my technician and/or instructions or these warnings. I understand that dishonest answers may cause permanent harm to myself. *
Initial
I am aware that it is my responsibility to inform the technician and/or esthetician, of my current medical or health conditions. I agree to update this history, as a current medical history is essential for the technician to execute appropriate treatment procedures and have read and completed this client intake form in its entirety and provided truthful answers. *
Initial
*By signing this form, you confirm that everything on this form is true to the best of your knowledge.*
Signature

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CLIENT INTAKE FORM

CLIENT HISTORY