Patch Test Form
This form must be completed prior to appointment.
Full Name
First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
example@example.com
Please select the applicable one(s)
I’ve had eyelash extensions before
I’ve had reactions to previous eyelash treatments.
I’ve had eye problems within the last 4 weeks.
Other
If you had reactions to previous eyelash treatments, please give details
If you had eye problems within the last 4 weeks, please give details
Do you have any allergies? (Please specify)
Max Lash Length Preference
14/15mm
15/16mm
16/17mm
17/18mm
18/19mm
Submit
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