Lash Lift Intake Form
Please complete this form before your lash lift appointment to ensure your safety and the best possible results.
Client Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Lash Lift History
Have you ever had a lash lift before?
Yes
No
If yes, when was the date of your last service?
Have you ever had irritation or an allergic reaction to a lash lift?
Yes
No
If yes, explain
Health and Eye Information
Do you currently have or have you ever had any of the following conditions?
*
Eye infections (e.g., conjunctivitis)
Chronic dry eyes
Skin conditions around the eyes
Recent eye surgery
None of the above
Do you have any allergies? (e.g., latex, adhesives, dyes)
*
No known allergies
Latex
Adhesives
Dyes
Other
Medical Disclosure
Are you pregnant or breastfeeding?
*
Yes
No
Please list any medications you are currently taking (if any):
Is there anything else we should know about your health or eye area?
Client Acknowledgment
By signing, I confirm the information above is accurate and complete. I understand that a lash lift involves chemical solutions and results may vary based on natural lashes and health history. I release the technician from liability related to undisclosed conditions or failure to follow aftercare instructions.
Client Signature
*
Date
*
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: