Intake Form
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
Emergency contact phone
Please enter a valid phone number.
Format: (000) 000-0000.
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Have you ever had a lash lift and tint before?
Yes
No
Have you ever reacted to:
Tint
Perm solution
Hair dye
Have you had eye surgery in the last 6 months?
Yes
No
Do you have:
Eye infection
Stye
Pink eye
Dry/watery eyes
Do you have any eczema or psoriasis around the eyes?
Yes
No
Are you currently using:
Accutane
Retinol around the eyes
Prescription ance medication
Have you had any chemical peel or laser treatment near the eye area recently?
Yes
No
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Contraindications
Please check all that apply
Pregnancy
Recent eye surgery
Recent lash loss
Active eye infection
Recent allergic reaction
Severe allergies
None
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Client Agreement
I understand my natural lashes determine my final results. I understand the lift gradually relaxes over approximately 6–8 weeks. I understand over-processing can occur if aftercare instructions are not followed. I understand tint may fade over time. I understand there is a risk of irritation or allergic reaction. I agree to keep my lashes dry for the recommended time following treatment (or follow the specific aftercare instructions provided by my technician). I agree not to rub or pull on my lashes. I understand results cannot be guaranteed. I consent to photographs.
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Liability Statement
I have answered all questions truthfully and understand the risks associated with lash lifting and tinting, including irritation, redness, allergic reaction, and uneven results. I voluntarily consent to receive the service.
Signature
Todays Date
-
Month
-
Day
Year
Date
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