Effortless Beauty Clinic: Lash Consultation Form
Email *
What is your name? *
Address, City, State, Zip *
Phone Number *
Date of Birth *
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Referred By
Allergies? *
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Do you have any other conditions or concerns that we should be aware of?
Lifestyle: *
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Previous Treatments? *
Required
Was your previous treatment experience positive? If not, please explain.
Conditions? *
Required
If Eye Surgery or Other in Question 10 was selected, please explain "other" or provide date of surgery
Skin Type? *
Required
Products Used? *
Required
Previous product reactions? Please specify.
Do you wear glasses? *
Required
Do you wear contact lenses? *
Required
Do you use eye drops? *
Required
If you use Rx eye drops, please specify.
Today's Date *
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