Client Consent Form
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you had eyelash extensions professionally done before?
Yes
No
Do you currently use eye antibiotics or medication?
Yes
No
Do you have and allergies or sensitivities?
Yes
No
If yes, please explain here:
Do you frequently have eye irritations such as watery eyes, dry eyes, or itchy eyes?
Yes
No
Do you wear contacts?
Yes
No
Have you had eye surgery in the past six months?
Yes
No
Signature
Submit
Submit
Should be Empty: