Registration Form - New Clients
Eyelash Extensions
Customer Details:
Full Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Have you ever had eyelash extensions or a removal in the past?
*
Yes
No
Yes I have a set right now from another lash tech
Have you had major surgery in the last 120 days? If so, please seek approval from your doctor.
*
Yes
No
Have you had chemotherapy treatments in the last 6 months? (These may cause allergic reactions to the products used)
*
Yes
No
Do you suffer from allergies to adhesives (glues, tapes, gels)? The eyes may be sensitive to eyelash extensions and products used to prepare the eye area.
*
Yes
No
Do you suffer from seasonal allergies?
*
Yes
No
Do you have permanent eye makeup?
*
Yes
No
Do you wear contact lenses on a regular basis? The glue used to apply eyelash extensions can get under the contact lens and cause corneal abrasion. These must be removed before the eyelash extensions procedure.
*
Yes
No
Do you have oily skin? Natural oils can break down the adhesives used to bond eyelash extensions more quickly. An eyelash shampoo is necessary and available for sale.
*
Yes
No
Do you suffer from an eye injury, blepharitis (inflamed eyelids), blepharoplasty or an autoimmune disease?
*
Yes
No
Are you taking any medications that can cause temporary hair loss?
*
Yes
No
Please accept the terms and conditions below
*
I hereby agree to have eyelash extensions applied to my natural eyelashes and consent to the placement and/or removal of the eyelash extensions by the licensed professional.
I understand that due to the natural eyelash cycle and normal wear and tear, I will need to maintain my eyelash extensions with touch-up appointments generally recommended every 2-3 weeks to keep them full and clean. Eyelash shampoos are available over the counter to maintain them properly. You also benefit from an eyelash treatment at the start of each appointment.
I understand that on rare occasions there are risks associated with having eyelash extensions, like any other cosmetic procedure. I further understand that in very rare cases, eye or skin irritation and discomfort may occur. I understand and agree to the aftercare instructions and also understand that any unforeseen circumstances that arise due to failure to follow these instructions are at my own risk.
I hereby grant Lashzone Inc. permission to use my likeness in a photograph, video or other digital media (“photo”) in any of its marketing materials and publications, including web postings, without payment or other consideration.
I
Full name
sign and certify that I have read and accepted the conditions above.
Please upload, if necessary, a photo of an application model that you would like to have on your eyelashes. Please note that the result may differ due to the shape of your eyes.
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