Intake Form
Lash Extensions
Please fill out to the best of your ability.
Name
First Name
Last Name
Date of birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Emergency contact
First Name
Last Name
Emergency contact number
Please enter a valid phone number.
Format: (000) 000-0000.
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Have you ever had Lash Extensions before?
Yes
No
Experiences with seizures or epilepsy?
Yes
No
Have you had an allergic reaction to:
Lash adhesive
Tape
Eye pads
Latex
Do you have sensitive eyes?
Yes
No
Do you wear contact lenses?
Yes
No
Have you had eye surgery in the last 6 months?
Yes
No
Do you currently have:
Pink eye
Eye infection
Stye
Excessive watering
Dry eye
Other
^ If other, please explain
Are you pregnant or breastfeeding?
Yes
No
Are you currently using any prescription eye medications?
Yes
No
Are you undergoing chemotherapy?
Yes
No
Do you have any skin conditions around the eyes?
Yes
No
Type option 4
^ If yes, please explain
Reference photos if desired
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Client Agreement
I understand lash extensions require maintenance every 2–3 weeks. I understand individual lash shedding is normal. I agree to arrive with clean lashes free of mascara and makeup. I understand results vary based on my natural lash health and home care. I understand rubbing, picking, or pulling at extensions may damage my natural lashes. I understand no guarantee is made regarding retention. I understand an allergic reaction can occur immediately or after multiple appointments. I understand if irritation develops after leaving the salon, I should contact a medical professional if symptoms become severe. I consent to phots being taken.
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Liability Statement
I acknowledge I have disclosed all known medical conditions and allergies. I understand the possible risks associated with eyelash extensions and services, including but not limited to irritation, redness, swelling, allergic reaction, discomfort, and temporary lash shedding. I voluntarily consent to receive this service.
Signature
Todays date
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Month
-
Day
Year
Date
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