Client Evaluation Form
Name
First Name Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Phone Number
Area Code Phone Number
Date
Month Day Year
Date
Health History - please list any allergies (inc. Cosmetic ingredients) or relevant medical conditions ? (Include any medications used)
Are you allergic to acrylate/cyanoacrylate (bonding agent) ?
Yes No Unsure
Have you ever had any of the following conditions?
Recent eye surgery or use contact lenses Pregnancy Cancer/ chemo Watery or sensitive eyes Thyroid issues
Is there any other condition or significant information we need to know about that may affect you during or after this procedure?
Disclaimer
Although every precaution will be taken to ensure your safety before, during and after your procedure, please be aware of the following potential risks and information;
I understand that lash extension, lash lift and lash tint services have some inherent risk of irritation to the orbital eye area, including the eye itself, and could result in stinging and burning, blurry should the adhesive enter the eye or should an allergic reaction occur.
Agree Do not agree
I understand that some irritation, itching or burning may occur on the skin if the bonding agent comes into contact with it.
Agree Do not agree
I understand that if the bonding agent comes into contact with my eye, my eye will be flushed with water and I will be assisted in seeking medical attention immediately.
Agree Do not agree
I understand that this is a semi-permanent procedure, as my natural lashes will continue to grow and fall out normally, making touchup or “fill” appointments necessary to maintain the original look achieved by replacing the lashes that have fallen out. Most clients require a fill appointment every 2-3 weeks
Agree Do not agree
I understand that it is imperative that I disclose all of the information requested in the Client Profile/Health History.
Agree Do not agree
I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications
Agree Do not agree
I understand that additional conditions could occur or be discovered during the procedure which could affect my ability to tolerate the procedure.
Agree Do not agree
I consent to “before and after” pictures for the purpose of documentation, potential advertising and promotional purposes.
Agree Do not agree
I understand that if I have any concerns, I will address these with my technician. I give permission to my technician to perform the lash extension procedure we have discussed, and will hold him/her and his/her staff harmless and nameless from any liability that may result from this treatment. I have accurately answered the questions above, including all known allergies, prescription drugs, or products I am currently ingesting or using topically. I understand my lash extension specialist will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult the lash extension specialist immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the lash extension specialist, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today.
Yes
Signature
Clear
Should be Empty:

Client Evaluation Form

Disclaimer