Consultation Form

EYELASH EXTENSION
Consultation Form
CLIENT INFORMATION:
Name

First nameLast name
Date of birth

MonthDayYear
Date
Age
Address
City
State
Zip
Phone
Format: (000) 000-0000.
Email
example@example.com
Emergency contact
Phone
Format: (000) 000-0000.
How did you hear about us
MEDICAL HISTORY:
Please check any applicable boxes and provide additional details where necessary. Do you have any of the following medical conditions?
Are you allergic to acrylic or latex? (Medical tape and adhesives required for eyelash extensions may contain acrylic or latex)
Do you wear glasses?
Do you wear contacts?
Do you have, or are you being treated for an eye injury/illness?
Do you often have eye irritation, itching, or watery eyes?
Do you have any other allergies?
Are you pregnant or trying to become pregnant?
Any recent surgery, including plastic surgery?
Please list all medications or supplements you take regularly:
EYELASH HISTORY:
Have you ever had eyelash extensions before? If yes: Were they applied by a professional?
Where were they applied
Why did you have them removed
By signing below, you agree to the following: I have completed this questionnaire truthfully and to the best of my knowledge. I understand that withholding information or providing inaccurate details about my medical history, allergies and medications may lead to adverse reactions to the treatments I undergo. I agree to inform the technician of any changes in the above information.
Client name
Signature
Date

MonthDayYear
Date
GLAM GODDESS BEAUTY BAR
Should be Empty:

EYELASH EXTENSION

Consultation Form

CLIENT INFORMATION:

MEDICAL HISTORY:

EYELASH HISTORY:

GLAM GODDESS BEAUTY BAR