Eyelash Extension Intake & Consent Form

Email address *

Name *

Please include first and last name.

Phone # *

Appointment Date & Time

YYYY

Time

How did you hear about us? *

If referred, please include name.

Is this the first time you have had eyelash extensions applied? *

Yes

Do you curl, perm, or tint your lashes? *

Yes

Are you having eyelash extensions applied for a special occasion or daily wear? *

Do you wear contacts? *

Yes

Do you habitually rub, pull, or pick your lashes for any reason? *

Yes

Occasionally

Do you have, or are you being treated for any eye illness or injury? *

Yes

What side do you predominately sleep on? *

Please list any eye drops or eye medication you are using:

Are you able to keep your eyes closed and lie still for up to 2 hours or longer? *

Yes

Please check any of the following that might apply to you:

Lasik eye surgery

Permanent eye make-up

Eye lift

Microdermabrasion

Allergies to adhesives or synthetics

Alopecia

Dry eye

Thyroid disease

Recent fever or illness

Iron deficiency

Hormonal imbalance or extreme stress

Eating disorders

Major surgery within the last 120 days

Cancer treatment

Anticoagulants

Oral contraceptives

Acne medication

Retin A (retinol)

Other:

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This form was created inside of Chelsea Kuzmin.