Eyelash Extension Form
Includes medical history, eyelash extension and appointment preferences, and consent & liability. Please fill it out truthfully and to the best of your ability, it should only take around 5-10 minutes. Should you have any questions or concerns, feel free to contact me at beautybyjemdj@gmail.com or Instagram @thebeautyjem.
Personal Information
Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Instagram username – this is my preferred form of contact (If you don't have one, I will be contacting you through text).
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Medical History
Please answer carefully and truthfully for your aesthetician to determine whether you are suitable and able to undergo the procedure and to rule out any contraindications.
Do you have any allergies? If yes, please explain.
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Are you on any medications? If yes, please explain.
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Do you have any medical condition(s) that may need accommodations during your appointment? If so, please explain what and how I may be able to accommodate you and provide a relaxing appointment.
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Do you have, or are currently being treated for an eye infection or eye injury? If yes, please explain.
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Have you had any reactions to lash products or glue before? If yes, please explain.
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Do you wear contact lenses? (If yes, please come to your appointment WITHOUT contact lenses as they will react with the glue fumes)
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Yes and I will come into the appointment without my contact lenses
No, I don't wear contact lenses
Would you like to do a patch test prior to your appointment? This tests for any allergic reactions to any products used and is typically scheduled 3 days prior to the appointment.
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Yes
No
What do you prefer during your appointment? (By the way, you can always ask for a silent appointment, just write it in your appointment notes when you book or let me know in person!)
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Music and talk
Podcast and listen
Own headphones/sounds
Silent appointment (minimal talking & music/podcast)
Other (please let me know at the appointment!)
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Eyelash Extension Preference
Please answer the following questions for your aesthetician to understand your lash preferences and goals.
Have you had eyelash extensions applied before? If yes, how often do you get them done?
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Yes I have and I get them done every month.
Yes I have and I get them done for special occasions.
No I haven't, this is my first time!
Do you have any concerns/fears/bad experiences from getting lashes done? Was there anything you didn’t like about your previous lashes? (Ex. length, shape, curl, procedure?)
Describe your eye makeup routine (Ex. Do you wear mascara, eyeliner, or eyeshadow & how often? Do you use a lash curler? What do you use to remove your eye makeup?)
What's your preferred lash set?
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Classic set
Hybrid set
Anime set
Wet set
Volume set
Mega volume set
What's your preferred lash shape?
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Cat eye
Doll eye
Natural eye
Open eye
Squirrel eye
What's your preferred minimum to maximum lash length? (If any)
What's your preferred lash curl? (If any)
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Consent & Liability
I confirm I am over the age of 18 or have obtained parental/guardian consent.
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Yes
No, but I will also get my parent/guardian to sign the Parent Consent form
I understand I am receiving a lash extension service from "THE BEAUTY JEM/JEMIMA DE JESUS". I understand this procedure requires synthetic eyelashes to be glued to my own natural eyelashes.
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Yes
No
I understand that it is my responsibility to keep my eyes closed and be still during the entire procedure, until my technician addresses me to open my eyes and that if I wear contacts I must remove them. Any medical conditions that might be aggravated by lying still in a horizontal position for a prolonged time may mean I will not be able to have the procedure performed on my eyelashes. I understand failure to keep my eyes fully shut throughout the whole procedure can lead to the risks listed below.
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Yes
No
I understand that some risks of this procedure may be, but not limited to, chemical burns, discomfort, eye redness and irritation. I understand that even though my technician will perform the service with precision and care, the fumes from the adhesive may cause my eyes to tear up if I open my eyes. Some clients may have an allergic reaction and require the eyelashes to be removed. I voluntarily assume all such risks and release my technician of all liability associated with receiving eyelash extensions.
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Yes
No
I confirm and agree to disclose all known allergies, eye conditions, medications, or medical issues that may affect the outcome or safety of this procedure. I disclosed all sensitivities I have to surgical tapes, cyanoacrylate, vaseline, latex, etc. and after my technician’s precautions I have still decided to proceed with application. I understand and agree that my technician will not be held responsible if I experience any issues with my eyes or lashes.
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Yes
No
I hereby grant to “THE BEAUTY JEM” the full right to take, publish and reproduce photographs of me, my face, my eyes and/or eyelashes, both before and after this procedure, solely for marketing purposes on a website or social media without any monetary compensation and/or discount vouchers.
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Yes
No
I agree to follow the care and maintenance instructions provided by the artist and that if any follow up care is required or failure to follow these instructions, I acknowledge this will be at my own expense and risk.
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Yes
No
I acknowledge that “THE BEAUTY JEM” does not accept refund requests. I agree to communicate any fallout or dissatisfaction within 72 hours of the appointment to guarantee a same week touch-up appointment or removal.
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Yes
No
I have read and understood the policies of “THE BEAUTY JEM” (found on her website or Instagram @thebeautyjem story highlights with the name “policy”). I understand that those policies and this consent and liability form will be in effect from now and all future appointments and will be applied if necessary and as “THE BEAUTY JEM” sees fit.
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Yes
No
I understand this agreement shall be governed by the laws of British Columbia. This agreement will remain in effect for this procedure, and all future procedures conducted by “THE BEAUTY JEM”. I release my aesthetician of “THE BEAUTY JEM/JEMIMA DE JESUS”, and the property owners of all liability and claims associated with this procedure.
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Yes
No
Signature – By signing below, I confirm I have read and understood the above information, had the opportunity to ask questions, and agree to receive the eyelash extension service.
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Submit
Submit
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