Name
*
First Name
Last Name
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)
Drugs that can cause temporary hair loss
Major surgery within last 120 days
Other
Have you ever had eyelashes extensions before?
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Yes
No
Please agree to the terms and conditions
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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 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 and prevent lash damage.
Client Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
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