New Client Intake Form - Lashes

First and Last Name

City, State, Zip

Phone

I consent to the application, removal, and/or retouching of eyelash extensions to my natural eyelashes by a licensed esthetician.

I understand there are risks associated with the application/ removal of eyelash extensions. Including, but not limited to: eye irritation/ discomfort.

I understand and consent to having my eyes closed throughout the procedure.

I agree to the aftercare instructions given by the technician and realize that failure to follow these instructions may damage natural lashes and/or decrease life of extensions.

I consent to having before and after pictures taken for advertising and marketing purposes. I understand these pictures may be posted to social media sites.

First time wearing eyelash extensions?

Yes

Current use of eye medications or antibiotics?

Yes

List allergies. Including, eye-related sensitivites.

Do you wear contacts?

Yes

Do you experience watery eyes, and/or itchy eyes?

Yes

Recent history of chemotherapy?

Yes

Any eye surgery within the last 6 months?

Yes

Please list any medical conditions that would inhibit or compromise the placement and retention of eyelash extensions.

By signing this form, I am acknowledging and understand all information listed. This agreement will remain in effect for this procedure, as well as all future follow-ups conducted by the technician. I consent to this agreement and the eyelash extension application/ removal procedure.

Signature

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