Eyelash Extension Intake Form

Eyelash Extension Intake Form

Holistic Glow Electrology & Wellness
Name

First NameLast Name
Phone Number
Emergency Contact

NameRelation
Emergency Contact Phone Number
Your Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?

WebsiteGoogleInstagramFriendOther
Health History | Please check any of the following that applies to you

Allergy to adhesives band aid or medical tapeAllergy to surgical glue or nail glueSkin conditions around the eyes (eczema, psoriasis, dermatitis)Allergy to glycerinEye illness or injuryBlepharitis (inflamed eyelids)Permanent eye-makeupEye liftDrugs that can cause temporary hair lossMedications that may affect healing (blood thinners, steroids, acne meds, etc.)Other
Eye infections (styes, conjunctivitis, blepharitis)GlaucomaDry eye syndromeContact lensesRecent eye surgery (within last 6 months)Lasik/PRK surgeryAllergies to latex, or cyanoacrylateAllergies to tape, gels, or eye padsChronic sinus issues or seasonal allergiesOther
Have you ever had eyelashes extensions before?

YesNo
If yes, where have you had them applied and what brand was used?
Eyelash Extensions – Before & After Care

Before Your Appointment:

Arrive with clean lashes (no makeup, mascara, or oils).
Avoid caffeine right before your appointment (it can make eyes flutter).
Remove contact lenses if possible.
Let me know about any allergies, eye conditions, or sensitivities before we begin.

After Your Appointment
Avoid water, steam, or sweating for the first 24 hours.
Do not rub, pull, or pick at your lashes.
Sleep on your back if possible to prevent crushing lashes.
Use only oil-free cleansers and makeup removers around your eyes.
Brush lashes gently with a clean spoolie daily.
Avoid mascara, eyelash curlers, or waterproof products.
Schedule refills every 2–3 weeks to maintain your look.
Please agree to the terms and conditions

I hereby agree to have eyelash extensions applied to my natural lashes and consent to the placement and/or removal of the eyelash extensions by the lash professional.I understand and agree to the after-care instructions and for any unexpected circumstance that have happened due to not following these instructions are in my own risk.I understand that in rare occasions there are risks associated with having artificial eyelashes. I further understand that in rare circumstances eye or skin irritation and discomfort may occur.I understand that because of the natural lash cycle and wear and tear, I will need to maintain my extensions with touch up appointments usually recommended about every 2 to 3 weeks to keep them full.
Date

MonthDayYear
Date
Client Signature

Clear
Should be Empty: