Skin Care Consultation Form

Lash Extension Consultation Form
Name*

First NameLast Name
Today's Date*
Phone Number*

Area CodePhone Number
E-mail*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birthday*
How did you hear about me?

InstagramFacebookReferralWebsite / Online SearchOther
If Referral, please list name
If Other, please let me know
Health Information
Do you have any allergies? (including cosmetics/ingredients)*

YesNo
If yes, please list allergies below
Are you allergic to Acrylate/Cyanoacrylate (bonding agent)?*

YesNoDon't know
Have you ever had a reaction to adhesive tape, topical creams, nail adhesives, or other topical products?*

YesNo
Do you have any eye disease, condition, or injury that has affected your lash growth/loss?*

YesNo
(optional) Please list any medications you are currently taking (including over the counter herbs, vitamins, and supplements:
Do you have any other health conditions?
These questions are relevant to your hair growth, and overall hair health. Please answer as fully as possible.
Have you ever had any of these conditions?

AlopeciaHormonal ImbalanceCancer/chemoThyroid DiseaseBlepharitisConjuntivitusRecent Eye SurgeryDry eyeWatery eyesSensitive eyesSensitivity to lightClaustrophobia
Are you pregnant or nursing?

YesNo
Do you wear contacts or glasses?

ContactsGlassesBothNeither
Have you had facial treatments?

YesNo
Have you received any Botox, Juvederm, or other dermal fillers?

YesNo
Do you use any lash growth products or serums?

YesNo
If yes, what product?
What side do you most often sleep on?

LeftRightStomachBack
How fast do you feel your hair grows?

FastNormalSlow
Is there anything else I should know?
General Liability Release
I understand that eyelash extensions require ongoing maintenance and that fill fees are based on length of appointment and time in between lash fills. If I wait too long between fills, I may need to pay for a new full set. If I no longer wish to wear the eyelash extensions, my Lash Artist will remove them and I will not try to remove them myself and there may be a fee for removal of the eyelash extensions.*

I agree
I understand that this is a semi-permanent procedure, as my natural lashes will continue to grow and fall out normally, making Lash Fill Appointments necessary to maintain the original look achieved by replacing lashes that have fallen out. Most clients require a fill appointment every 2-3 weeks.*

I agree
Sleeping on my face, extreme weather changes, steam, sauna, wearing makeup/mascara, and other activities may damage the adhesive or crimp the extensions and may require more frequent refills. I reviewed and understand the aftercare instructions and will do my part to help maintain my eyelash extensions.*

I agree
I will seek medical care (at my own expense) and contact Studio Kalon LLC immediately if any allergic or adverse reaction occurs. All of my questions were answered and I understand the procedure and risks.*

I agree
I grant permission to use my before and after photos for marketing or examples of my Lash Artists work. (Before and after photos are a permanent part of the Lash Artist’s records. You may opt out of marketing purposes)

I agree
I release Studio Kalon LLC and Lash Extension Artist from any and all liability associated with this procedure (which will be performed with the utmost attention to safety and proper application using tools and products that the Lash Artist has been trained to use. This procedure has many variables due to lifestyle, moisture, weather, extreme temperatures, natural eyelash shedding, and other factors. The Lash Artist will assess and decide if I am a candidate for this service to the best of their ability. No guarantees are made or implied.*

I agree
Reservation & Cancellation Policy for all current and future appointments: a valid credit card is required for all appointments. Please do not forget to confirm your appointment when you receive your reminder from Square. In the event of cancellations received less than 24 hours prior to an appointment, a cancellation fee equal to 50% of the reserved service booking will incur. No Shows will be charged 100%.*

I understand the reservation and cancellation policies at Studio Kalon LLC and consent to my credit card on file being charged if I fail to give 24 hour notice for appointments scheduled.
By signing below, I verify that I have read and understand the above statements and agree to them.*

Yes
Signature or, if under 18 years old, Parent/Guardian Signature*
Should be Empty:

Lash Extension Consultation Form

Health Information