SOCAL ESTHETIX

SOCAL ESTHETIX

LASH CLIENT INTAKE FORM
Name

First NameLast Name
DOB

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
EMERGENCY CONTACT + PHONE NUMBER
MEDICAL HISTORY
DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING CONDITIONS? PLEASE SELECT ALL THAT APPLY.

Other
ARE YOU ALLERGIC TO ACRYLIC OR LATEX?
DO YOU HAVE ANY OTHER ALLERGIES I SHOULD BE AWARE OF?

Other
ARE YOU OR COULD YOU BE PREGNANT?
PLEASE LIST ANY MEDICATIONS YOU TAKE REGULARLY.
I am informing the certified eyelash technician that I have any of the following conditions by marking with a check in the boxes below:
do you need to make any additional medically related notes?

MAKE A SELECTION.

Rows	YES	NO
DO YOU WEAR GLASSES?
DO YOU WEAR LENSES?
DO YOU HAVE, OR ARE YOU BEING TREATED FOR ANY EYE ILLNESS/INJURY?
DO YOU OFTEN HAVE EYE IRRITATION, ITCHING, OR WATERY EYES?

EYELASH HISTORY

Rows	YES	NO
HAVE YOU EVER HAD EYELASH EXTENSIONS BEFORE?
IF YES, WERE THEY APPLIED BY A PROFESSIONAL?

WHERE WERE THE LASH EXTENSIONS APPLIED?
REASON FOR REMOVAL?
DO YOU USE ANY OF THE FOLLOWING PRODUCTS ON YOUR EYELASHES?

Other
have you had any of the following done to your lashes?

Other
post treatment & home care
Your lash extensions are attached to your own individual eyelashes, and will shed as your natural lashes shed. Maintaining your lash extensions will require regular visits to attach new extensions (refills) to your own eyelashes as your eyelash growth cycle regenerated new lashes.

With a few simple care instructions you will be on your way to enjoying your beautiful lashes. To increase the longevity of your lashes, it is advised to avoid moisture and touching as much as possible.

Before your appointment:

If you use waterproof mascara, avoid using it 2-3 days before your first appointment. The film it leaves on your lashes may prevent the extensions from adhering correctly.
Arrive to your appointment with dry, clean lashes and makeup-free eyes.
Remove contact lenses before your appointment.

During the initial 24-48 hours after your appointment:

Do not get your lashes wet for 24 hours after the lash extensions are applied. It will affect the efficacy of the glue.

Avoid steam from showers, facials, saunas and swimming pools.
Avoid getting moisture around the eye area when washing face, showering, etc.
Avoid tanning beds for 48 hours after application.
Avoid chemical peels, waxing or laser treatments around the eyes.
General guidelines to extend the life of your lashes

Avoid using oil-based skincare and makeup products around the eye, including mascara and makeup remover.
Avoid water mascara. If you can, it is between not to use any mascara at all. You may find you don't even need it!
Avoid rubbing your eyes or lashes, especially when washing your face. It is recommended to clean around the eye area with a washcloth or cotton swab (Q-tip) or with a Lash Bath Kit. If you are unsure of how to properly wash your lashes please inform your tech.

Avoid using an eyelash curler. One of the benefits of lash extensions is the ability to add curl to your lashes. If you would like more curl, please speak to your technician.
If you can, sleep on your back to avoid the risk of lashes rubbing against your pillow.
Gently brush your lashes with a mascara wand to groom them. The best time to do this is after showering, as they will be softer and less likely to damage. It is best to dry your lashes on a cool setting.

Avoid pulling your lashes, and do not attempt to remove them yourself. If you would like them removed, please contact your technician.
If you experience and pain, redness or irritation; contact your technican immediately.
informed consent

Although every precaution will be taken to ensure your safety and well-being before, during and after your lash extension application, please be aware of the following information and possible risks. Please Initial:
I understand that the lash extension services have some inherent risk of irritation to the orbital eye areas, including the eye itself, and could result in stinging and burning, blurry vision and potential blindness should the adhesive enter the eye or should an allergic reaction occur
initial
I understand that some irritation, itching or burning may occur on the skin if the bonding agent becomes into contact with it.
initial
I understand that if the bonding agent comes into contact with my eye, my eye will be flushed with water and I will be assisted in seeking medical attention immediately.
initial
I understand that this is a semi-permanent procedure, as my natural lashes will continue to grow and fall out normally, making touch-up or “refill” appointments necessary to maintain the original look achieved by replacing the lashes that have fallen out. Most clients require a fill appointment every 2-3 weeks.
initial
I understand that while every attempt will be made to provide me with the length and fullness I have chosen, my final result may not be what I initially envisioned.
initial
I understand that while every attempt will be made to provide me with the length and fullness I have chosen, my final result may not be what I initially envisioned.
initial
I understand that it is imperative that I disclose all of the information requested in the client profile/health history.
initial
I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications.
initial
I understand that additional conditions could occur to be discovered during the procedure which could affect my ability to tolerate the procedure.
initial
I consent to “before and after” photographs for the purpose of documentation, potential advertising and promotional purposes. if you do not consent photos are still required to be taken but not shared publicly for advertising or promotional purposes.
initial
Is there anything I can do that your previous tech didn’t do that could enhance your experience?
Do you require any additional accommodations?
Future Appointments/ Contact

Rows	Yes	No
May I call you at your phone number to confirm future appointments?
May I text you to confirm?
May I contact you via mail/email about future promotions and news?

Service Consent:
I agree to have eyelash extensions applied to my natural eyelashes and/or removed and retouched. By signing this agreement. I consent to the placement and/or removal of the eyelash extensions by the certified eyelash extension professional. I understand that there are no refunds. In the rare occasion that something happens to my lashes including premature fall out or an issue with the lashes I understand I have 72hrs from the completion of my appointment to inform my certified lash professional so she may fix as deemed necessary. I understand that in rare occasions there are risks associated with having artificial eyelashes and eyelash extensions applied to or removed from my natural eyelashes. I further understand that in rare cases as part of the procedure eye irritation and discomfort could occur. I agree that if I experience any of these conditions with my lashes that I will contact the certified eyelash extension professional that performed this procedure and it may be beneficial to have the eyelashes removed. I understand and agree to the after care instructions provided by the certified eyelash extension professional for the use and care of my eyelash extensions. I realize and accept the consequences of failure to adhere to these instructions may cause the eyelash extensions to fall out and/or decrease the time the lashes will last.

I understand and consent to having my eyes closed and covered for the duration of approximately 2-4hrs. Times may vary depending on the type and number of eyelashes applied.

I understand that if I have any concerns, I will address these with my lash extension specialist. I give permission to my lash extension specialist to perform the lash extension procedure we have discussed, and will hold her and her staff harmless and nameless from any liability that may result from this treatment. I have accurately answered the questions above, including any known allergies, prescription drugs or products I am currently ingesting or using topically. I understand my lash extension specialist will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult the lash extension specialist immediately. I agree this constitutes full disclosure, and that is supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the lash extension specialist, Suthern Rodriguez, responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed.
Signature
Date

MonthDayYear
Should be Empty:

MEDICAL HISTORY

EYELASH HISTORY

post treatment & home care

informed consent

Future Appointments/ Contact

Service Consent: