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Guest Intake Form
Full Name
First Name
Last Name
What is your age?
Contact Number
Format: (000) 000-0000.
Is this the first time you’ve had lash extensions?
Please Select
Yes
No
Do you use contact lenses?
Please Select
Yes
No
Have you worn any of the following lashes in the last 10 days?
Clusters
Strip Lashes
Semi Permanent Lashes
Have you gotten a lash lift in the last 30 days?
Please Select
Yes
No
Please check off any of the following that apply to you:
Extreme Stress
Hormonal Imbalances
Birth Control
Thyroid Medication
Pregnancy/ Breastfeeding
Retinoids
Blepharoplasty
Alopecia
Ringworm
Childbirth within 120 days
Iron Deficiency
Seasonal Allergies
Accutane
LASIK
Dry Eye
Blepharitis
Contact Dermatitis
Medication that contribute to hair loss
Compulsive Picking/ Pulling of Hair
Recent Permanent Makeup
Sensitivity to Cyanoacrylate
None
Other
Are you allergic to acrylic or latex?
Yes
No
Do you know if you are allergic to any adhesive, solvents, dyes or metals?
Yes
No
Not Sure
Are you wanting eyelashes for everyday wear or a special event?
Please submit a passport style photo
Browse Files
Drag and drop files here
Choose a file
This is to determine what eye shape you have in order to give you the best fitting lash look.
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