Lash Lift and Brow Lamination
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Post Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Gender and pronouns
Eg. She, Her,He, Him….
Race & ethnicity '
Appointment you've chosen
*
Medical History
Have you had surgery in the last 6 months
Do you have any pre-existing medical conditions?
Do you take any medications?
Do you have broken skin in the area being treated
Yes
No
Do you have any allergies?
Do you have any reactions to Latex?
Do you frequently have any of these?
Eye irritation
Watery eyes
Itchy eyes
None
Are you pregnant or breastfeeding?
Pregnant
Breast feeding
None
Consultation
If you are having lashes done, do you have lash extensions on?
Yes
No
Have you gotten this service done before?
Yes
No
Have you had a previous bad experience?
Do any of these apply to you?
Eye infection
Dry eyes
Seasonal allergies
Permanent eye makeup
None
How did you hear about us?
Friends
Family
Social media
Google
Other
What colour would you like your dye to be?
Black
Blue black
Brown
Do you accept our terms & polices?
*
Yes
Signature
*
Continue
Continue
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