Eyelash Extension

Eyelash Extension Consultation Form
Appointment Date

MonthDayYear
Date of appointment
Hour MinutesAM/PM Option
Client Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Apt. Unit

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Emergency Contact Information

First NameLast Name
Emergency Contact Number
Format: (000) 000-0000.
Have you had eyelash extensions applied before ?
If yes, why did you remove them?
Do you wear glasses?
Do you have frequent eye irritation, itching, or watery eyes?
Have you had eye surgery in the last six months?
*Eyelash extensions require medical tape and adhesives that may contain acrylic or latex.
Are you allergic to latex?
Are you allergic to acrylic?
PLEASE CHECK ANY OF THE FOLLOWING THAT MAY APPLY TO YOU:
RELATING TO THE EYE
GENERALLY RELATING TO EYELASHES
Other Medical Information
If none, please submit N/A
By checking the following boxes, confirm that you willingly consent to the following terms and conditions:
Client Signature
Date

MonthDayYear
Date
Should be Empty:

Eyelash Extension Consultation Form