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:
AlopeciaAllergiesBlepharitisBlepharoplastyCancer/ ChemotherapyChildbirth within 120 daysConjunctivitisPermanent eye makeup in last monthPsoriasis around the eyeThyroid diseaseRecent eye surgeryRecent eye infectionSensitivityNone
AcrylicLatexNeither
YesNo
YesNo
YesNo
YesNo
Do you have any other allergies?
YesNo
Any recent surgery, including plastic surgery?
Please list all medications or supplements you take regularly:
EYELASH HISTORY:
YesNoN/A
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: