Eyelash Extension

Eyelash Extension Consultation Form
Appointment Date *

MonthDayYear
Date
Hour MinutesAM/PM Option
Client Information
Name*

First NameLast Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
YesNo
If yes, why did you remove them?
YesNo
YesNo
*Eyelash extensions require medical tape and adhesives that may contain acrylic or latex.
YesNo
YesNo
PLEASE CHECK ANY OF THE FOLLOWING THAT MAY APPLY TO YOU:
Eye surgeryEye illness or injuryDry eyesSeasonal allergiesEye InfectionPermanent eye make-upBlepharoplastyBlepharitis (inflammation of eyelids)Allergies to cyanoacrylate adhesives (i.e. surgical glue, nail glue, crazy glue)Hypersensitivity to formaldehyde ( aby-product released in cyanoacrylateadhesives)Retinoids used to treat acne and skin problems (such as accutane or retin a)
Hormone imbalanceRecent severe illness or injuryPregnancy or recent childbirthNew prescriptions or recently prescribed oral contraceptivesTypes of medical conditions that may contribute to hair and eyelashloss: hyperthyroidism or hypothyroidism, alopecia areata, lupus, diabetesVitamin and mineral deficiencies that may contribute to hair and eyelash loss:A, F, B, Selenium, Zinc, IronTrichotillomania (hair pulling disorder)Medications that may contribute to hair or eyelash loss: chemotherapeutic agentsused in cancer treatment, Anticoagulants(blood thinners), beta blockers (used tocontrol blood pressure)
Other Medical Information
Client Name

First NameLast Name
Client Signature
Date

MonthDayYear
Date
Date

MonthDayYear
Date
Should be Empty:

Eyelash Extension Consultation Form