New Lash Client Intake Form
Please take a moment to fill out my new client consent form. This form is needed to book your appointment and must be completed before your service begins. Thank you!
Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Email
example@example.com
Health History | Please check any of the following that applies to you
Allergy to adhesives band aid or medical tape
Allergy to surgical glue or nail glue
Seasonal allergies
Allergy to glycerin
Eye illness or injury
Blepharitis (inflamed eyelids)
Permanent eye-makeup
Eye lift
Drugs that can cause temporary hair loss
Major surgery within last 120 days
Other
Have you ever had eyelashes extensions before?
Yes
No
If no, would you like to have a patch test which we highly recommend? (Note that a patch test does not guarantee that an adverse reaction will never happen)
Yes
No
How did you hear about me?
Website
Instagram
Referral
Other
Please agree to the terms and conditions
I hereby agree to have eyelash extensions applied to my natural lashes and consent to the placement and/or removal of the eyelash extensions by the certified professional.
I understand and agree to the after-care instructions and for any unexpected circumstance that have happened due to not following these instructions are in my own risk.
I understand that in rare occasions there are risks associated with having artificial eyelashes. I further understand that in rare circumstances eye or skin irritation and discomfort, or an allergic reaction may occur and it is my responsibility to seek medical attention.
I understand that because of the natural lash cycle and wear and tear, I will need to maintain my extensions with touch up appointments usually recommended about every 2 to 3 weeks to keep them full.
I give consent to have my photo taken for documentation which may also be used for advertisement.
I understand that results will vary from client to client. Results are not guaranteed.
I understand that in the case of a no-show or a cancellation of my appointment with less then 24 hour notice, my credit/debit card on file will be charged a fee of $25.
I will not hold the business or owner responsible for any claim or damage that may occur due to the service.
I understand a $25 deposit is required at the time of appointment request to hold my appointment time.
Date
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Month
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Day
Year
Date
Client Signature
Submit
Submit
Should be Empty: