Eyelash Extension

Eyelash Extension Consultation Form
Appointment Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Client Information
Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Have you had eyelash extensions applied before ?
If yes, why did you remove them?
Do you wear glasses?
Do you have frequent eye irritation, itching, or watery eyes?
*Eyelash extensions require medical tape and adhesives that may contain acrylic or latex.
Are you allergic to latex?
Are you allergic to acrylic?
PLEASE CHECK ANY OF THE FOLLOWING THAT MAY APPLY TO YOU:
RELATING TO THE EYE
GENERALLY RELATING TO EYELASHES
Other Medical Information
Client Name

First NameLast Name
Client Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Eyelash Extension Consultation Form