Consultation Form
Welcome to Elle 4 Lashes! We’re thrilled to get to know you and tailor our services to your needs. Please fill out this form to help us ensure your experience is as fabulous as possible.
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What's your full name? *
Name you prefer to use? *
Alias you go by usually, if different from name on credit card.
What's your phone number? *
May I text you? *
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What’s your full home address? We love sending birthday cards to our clients! *
What's your birthday? *
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Which services are you interested in? List as many as you wish, and feel free to share any specific goals or concerns you have with these services. *
Have you tried any of these services before?
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If yes, did you experience any adverse reactions or issues with the service or maintenance?
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If yes, did you seek a doctor or specialist's care?

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If yes, please explain.

To ensure your safety and the best possible results from our services, please list any conditions with regard to your health, allergies or lifestyle. Below are some suggestions to help you think of as many as possible. This information helps us tailor your experience while considering any contraindications:

Skin Sensitivities: Including reactions to eye treatments, adhesives, latex, or any known allergies (e.g., aspirin, environmental).
Eye Health: Such as recent surgeries, infections, diseases, or conditions like dry eyes or Bell’s Palsy.
Skin Conditions: Including eczema, psoriasis, recent sun/spray tans, or undergoing treatments that affect skin sensitivity (e.g., acne medications, retinols).
Lifestyle Factors: High caffeine intake, water consumption, difficulty lying still, claustrophobia, or anxiety.
Medical Treatments: Recent chemotherapy, immune disorders, use of blood thinners, or medications with side effects affecting hair/skin.
Other Relevant Conditions: Including but not limited to iron deficiency, exercise frequency, or wearing contact lenses.

For Specific Services:

Lash Extensions: Acknowledge that conditions mentioned above can affect lash retention and outcome.
Lash Lift & Tinting: Recognize potential impacts on lash health and service durability.
Waxing: Please list any medications affecting skin sensitivity or response to sunlight.
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For Lash Extension Clients, please acknowledge:  I understand that any of the above can contribute to retention issues or premature fallout of natural lashes and not disclosing a condition can make troubleshooting your retention issues much harder if you have them.
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I acknowledge and agree to the financial investment required for maintaining luxury eyelash extensions.
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For Lash Lift Clients:  I understand that any of the above conditions can affect the natural lash and its strength, ability to grow and how well they hold the curl or the length of time the lift lasts. *
For waxing clients: please list any relevant medications from your doctor with labels that have warned against exposure to sunlight or have skin thinning side effects.  If unsure, please consult your medications and physician.
Please read and select an option below:
Authorization: I authorize the use and disclosure of my name (or selected pseudonym), photographic/video images and/or testimonials for marketing purposes by Elle 4 Lashes, LLC. I understand information disclosed pursuant to this authorization may be subject to redisclosure and may no longer be protected by HIPAA privacy regulations. Purpose: The photographic/video images and/or testimonial will be used for Social Media, Advertising and/or Education Revocability: I understand that I may revoke this authorization at any time, but such revocation must be in writing and received by Elle 4 Lashes, LLC. via registered mail. Revocation affects disclosure moving forward and is not retroactive. This authorization expires 99 years from date signed.
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I agree to have eyelash extensions applied to my natural lashes.  Before my qualified service provider performs this service, I agree to complete this form truthfully and accept all aftercare requirements to protect my investment. *
Aftercare - I agree to accept all aftercare requirements provided below. I understand that eyelash extensions require meticulous care. I understand that it is not recommended to ever remove my eyelash extensions at home. If I neglect to take care of my eyelash extensions it will be at my own risk and expense.
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Informed Consent - I have read and agreed to this intake form in its entirety and I have been properly advised of the potential harm or side effects that may be caused by a specific medical condition listed above.

For Lashes: I understand that the professional eyelash adhesive, remover or chemicals used on me during the service can potentially irritate the skin, eye or follicles.  I understand that in rare cases, I could be allergic to cyanoacrylate, solvents, solutions for perming, tints, tapes or pigments that are present in lash services.

For Waxing: I understand that the professional application and removal of hard wax to remove unwanted hair is a service that can potentially irritate the skin and have unwanted side effects such as ingrown hairs, etc.  I understand that there are at home instructions to have the best experience with your wax service that is explained to you at your appointment.  Not following instructions can cause issues like ingrowns, rashes, skin lifting, peeling, prolonged sensitivity, etc. and it is up to you to make sure your skin is properly cared for to avoid these issues.
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Required
Please read through to the end, then confirm below:

Allergic reactions can happen during, immediately following, or hours after the service was performed but almost always within the first 24-48 hours of contact.

In the event of a negative reaction, whether due to an allergy or unknown reason, use your best judgement as to whether you should seek professional care.  If it's affecting your eye area and/or vision is impaired, or in the rarest of occasions you experience tightening of the throat or chest or inability to breathe, call 911 immediately.

If the symptoms are mild and you are able to have them removed, contact me for a free removal as soon as possible.  Reasons I may not be able to perform a removal is if the reaction is more severe where the area around the eye is swollen, irritated, broken, or unable to completely close the eye, then you will need to consult with your doctor first for something to reduce the symptoms and clear you for a removal.

Patch tests can be performed 24-48 hours prior to your service, however a negative result does not 100% guarantee a reaction will not occur from your service.  Patch tests are not required and may be waived, if preferred. 

If you experience anything regarding your service that is causing discomfort, irritation or itching etc. please contact me as soon as possible to discuss your options.  The sooner I can help you the sooner you'll feel better.  Be prepared to send photos of the affected area so I can determine how best to help.

Although we take pride on doing our best to minimize the likelihood that anything occurs, it is important for you, the client, understand the risks mentioned cannot be completely eliminated.

By agreeing to receive our services/products, you, the client, confirm that you have been fully informed of the aforementioned risks and the nature of the services/products provided. You acknowledge that your decision to receive services/products from Elle 4 Lashes is made with the full knowledge of the potential outcomes associated with such services/products.

To the fullest extent permitted by law, you hereby release, waive, discharge, and covenant not to sue Elle 4 Lashes, its officers, employees, agents, heirs, and assigns from any and all liabilities, claims, demands, actions, and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by you, or to any property belonging to you, while participating or otherwise engaging in the services/products provided by Elle 4 Lashes.
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One last question, how did you find me?
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If referred, by whom?
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