Lash Extension Intake Form

Lash Extension Intake Form
Name*

First NameLast Name
Pronouns (she/her, they/them, he/him, etc)*
Date Of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Date*

MonthDayYear
Date
YesNo
YesNo
If yes to above, about how long ago was your last lash lift and tint?
YesNo
YesNo
If yes to above, please explain.
YesNo
Lasik surgeryDry eyeAllergies to syntheticsSensitive eyesSensitive skinPermanent eye makeupHistory of BlepharitisHistory of Pink EyeHistory of StyesHistory of ChemotherapyHistory of Radiation therapyNone
No waterproof mascara or makeup with oil.No oil based products around the eye areaNo water can come in contact with the eye area for 24 hours after initial applicationNo pulling, tugging, or rubbing of the lash extensionsNo excessive high heat or steaming of the lash extensions which can cause fallout, distortion and straightening of the lashes.No sleeping on your face to avoid crushing the lash extensionsNo lash curlers should be usedNo picking and removing lashes myselfIf I am pregnant I have consulted a physician prior to my appointmentShould any eye drops be necessary extra care should be taken to prevent moisture in the lash extensions and they should be cleaned afterwardsI will clean my lash extensions with an oil free lash shampoo at a minimum of every other dayI understand that my lifestyle can contribute to and is involved in my lash extension retention and there is no guaranteed of the lifespan of the extensions.
I agree and understand the importance of proper aftercare and maintenance for lash extensions
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I First* Last Name* understand the importance of disclosing the correct medical history information and have not withheld anything that could contraindicate my lash extension service. I give consent for my esthetician to apply, fill, and or remove my lash extensions.
By signing this I give consent to the placement/ removal of lash extensions by certified and licensed esthetician Jordan Owens. I understand synthetic lash extensions will be applied to my natural lashes after isolating a single natural lash.

I understand that I am required to keep my eyes closed for an extended period of time (2-4 hours) and that opening my eyes prematurely can expose them to fumes that may irritate or cause a reaction.

I agree to remove contact lenses as the adhesive may react with them causing irritation and damage to the eye and surrounding areas. I understand there is a rare chance that this service can cause redness, irritation, allergic reactions, and natural lash damage without proper aftercare.
I understand my natural lashes will grow and fall out and that fill appointments are required every 2-3 weeks to maintain the eyelash extensions and lash health.

I understand that should an allergic reaction occur, a refund will not be issued but I can request a free removal of the eyelash extensions.
I understand proper aftercare must be followed to keep my extensions clean and healthy.
I understand and agree that by signing this waiver I release Jordan Owens and The Lunar Cottage L.L.C from any expenses, liabilities, and damages that may arise from this service, or future services or purchases.
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