Name
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
Format: (000) 000-0000.
How did you hear about us?
Google
Instagram
Facebook
Friend
Other
Health History | Please check any of the following that applies to you
Allergy to adhesives band aid or medical tape
Allergy to acrylic or latex
Alopecia
Allergies (General)
Allergy to glycerin
Blepharitis (Inflamed eyelids)
Cold sores
Cancer
Diabetes
Drugs that can cause temporary hair loss
Eczema/Psoriasis
Eye lift
Eye illness or injury
Glasses or contacts
Major surgery within last 120 days
Permanent eye-makeup
Skin History | Check if any apply.
Are you using any Alpha Hydroxy Acid (AHA) or glycolic products in the past 72 hours?
Are you using Benzol Peroxide?
Are you using Rein-a, Renova, or Accutane?
Are you using any other skin thinning products and/or drugs?
Do you use a tanning bed?
Have you ever had a waxing treatment before?
Have you ever had a reaction to waxing?
Any other skin history I should be made aware of?
Have you ever had eyelashes extensions before?
Yes
No
If you have had or currently have lash extensions, which style do you have?
Please Select
Classic
Hybrid
Volume
Unknown
Have you ever had a lift and tint or brow lamination before?
Yes
No
Do you use any of the following products on your eyelashes?
Mascara
Serum
Curling Wand
Lift (Perm)
Tint
Have you ever had any hair removal procedures before?
Yes
No
Please agree to the terms and conditions
I understand that in rare occasions there are risks associated with having beauty/spa procedures. I further understand that in rare circumstances eye or skin irritation, eye itching, and discomfort may occur. If I experience any medical conditions relating to the procedure received that I will contact my technician and consult a physician at my own expense.
I understand that some mild but normal symptoms may occur with the brow lamination depending on the sensitivity of my skin during the procedure and will subside in 24 hours.
I understand that if adverse reactions occur or I am not fully satisfied with the results of the procedure preformed I am still required to pay for the procedure and time taken from the certified professional. Under certain conditions, a removal of lash extensions or a reapplication of the perming and/or tinting solution can be offered free of charge to the certified professional’s discretion.
I agree to the following follow-up maintenance for lift/laminations and tinting: No water can come in contact with the eye or brow area for 24 hours after the application. Avoid makeup or using oils for the first 24 hours. Try to use oil-free makeup remover at all times. No pulling or rubbing at the area. Chlorine and certain skincare products will shorten the effects of the perm, tints, or extensions.
I agree to the following follow-up maintenance for lash extensions: No tinting or curling eyelash extensions. No pulling or rubbing at the area. Avoid exposure to excess heat. Chlorine, salt water and certain skincare products will shorten the effects of the extensions.
I understand and agree to the after-care instructions and for any unexpected circumstance that have happened due to not following these instructions are at my own risk.
I understand that because of the natural lash cycle and wear and tear, I will need to maintain my extensions with touch up appointments recommended about every 2 to 3 weeks. After 4 weeks I may require a full set.
I understand and consent to the cancellation policy of Bloom Lash Suite.
I have read and fully understand all information in this agreement. I am over 18 years of age and consent to the agreement and to the procedure provided. I have completed this form truthfully and to the best of my knowledge. I agree to inform the technician of any changes in the above information. I agree to waive all liabilities toward my technician and the employer for any injury or damages incurred due to any misrepresentation.
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