Eyelash Extension Intake & Consent Form
* Required
Email address
*
Your email
Full Name
*
Please include first and last name.
Your answer
Phone #
*
Your answer
Appointment Date & Time
MM
/
DD
/
YYYY
Time
:
AM
PM
How did you hear about us?
*
If referred, please include name.
Your answer
Is this the first time you have had eyelash extensions applied?
*
Yes
No
Do you curl, perm, or tint your lashes?
*
Yes
No
Are you having eyelash extensions applied for a special occasion or daily wear?
*
Choose
Daily Wear
Special Occasion
Both
Do you wear contacts?
*
Yes
No
Do you habitually rub, pull, or pick your lashes for any reason?
*
Yes
No
Occasionally
Do you have, or are you being treated for any eye illness or injury?
*
Yes
No
What side do you predominately sleep on?
*
Choose
Right
Left
Both/Neither
Please list any eye drops or eye medication you are using:
Your answer
Are you able to keep your eyes closed and lie still for up to 2 hours or longer?
*
Yes
No
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:
Required
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