Lash Lift Consultation Form

Lash Lift Consultation Form
Today's Date
Full Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Birthday*

MonthDayYear
Date
How did you hear about me?

InstagramFacebookGoogleReferralOther
Name of Person Who Referred You
Please list any allergies you have (including cosmetics/ingredients) *
Do you have any eye disease, condition, or injury that has affected your lash growth/loss?*

YesNo
Have you ever had a reaction to adhesive tape, topical creams, nail adhesives, or other topical products?*

YesNo
Please list any medications you are currently taking (including over the counter herbs, vitamins, and supplements:
Are you pregnant or nursing?*

YesNo
Do you have any other health conditions?
If you have had any of these conditions, or previous discomfort, stinging, or adverse reactions, please check

Skin DisordersInflammation of the SkinEye InfectionsBlepharitisWatery EyesRecent Eye SurgeryHayfeverBell's PalsyConact Lenses
Have you ever had any of these treatments before? If so, which ones?

Eyelash or brow tintingEyelash extensionsEyelash perm/liftSemi permanent mascara
Have you a reaction to any of those treatments? If so, which one(s) & please explain
Do you use any lash growth products or serums?*

YesNo
Additional information you'd like me know
General Liability Release
I consent to these procedures being carried out today without undergoing a sensitivity patch test. The sensitivity test, which if conducted, may indicate my sensitivity / allergy to the products. I understand the contents of this form and take full responsibility for my actions, thus absolving all other parties of their responsibilities, if any, associated with the supply of the products and services(s).*

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 the technician's work. (Before and after photos are a permanent part of the technicians’s records. You may opt out of marketing purposes)

I agree
I release Studio Kalon LLC and technician 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 technician has been trained to use. This procedure has many variables due to lifestyle, moisture, weather, extreme temperatures, natural eyelash shedding, and other factors. The technician 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.
Signature or, if under 18 years old, Parent/Guardian Signature *

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Lash Lift Consultation Form

General Liability Release