Form
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Please check any of the following conditions that apply to you.
*
Glycerin allergy
Latex allergy
Iron deficiency
Alopecia
Sensitive/watery eyes
Dry eyes
Pregnancy
Hormonal imbalance
Extreme stress
Claustrophobic
Medication that causes hair loss
Chemotherapy in the last 6 months
Recent Lasik surgery
List any other conditions.
*
Is this your first time getting lash extensions?
*
Yes
No
Are you getting lash extensions for daily or special occasion wear?
*
Daily wear
Special occasion
Do you wear contacts/glasses?
*
Contacts
Glasses
None
Would you prefer a silent appointment?
Yes, I prefer a silent appointment.
No, I’m okay with conversation.
No preference.
I grant Laci Aesthetics permission to use my before and after photos for marketing and /or social media purposes.
*
Yes
No
If you have any inspiration photos, please attach them below.
Browse Files
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I have completed this intake form truthfully. I understand that withholding information or providing misinformation may result in contraindications and /or irritation to the eyes from fumes/glue.I have voluntarily received lash extension service. I have been informed about the procedure and provided accurate information. I understand there is risk involved with lash extensions, including allergies, reactions or damage to natural lashes. I release Laci Aesthetics from any liability that may arise from this treatment.
*
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