Eyelash Extension

Eyelash Extension Consultation Form
Appointment Date
MonthDayYear
Date
Hour MinutesAM/PM Option
Client Information
Name
First NameLast Name
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Phone Number
Email
example@example.com
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YES! Sign me up!No, Thank you
Have you had eyelash extensions applied before ?
YesNo
If yes, why did you remove them?
Do you wear glasses?
YesNo
Do you have frequent eye irritation, itching, or watery eyes?
YesNo
Have you had eye surgery in the last six months?
YesNo
*Eyelash extensions require medical tape and adhesives that may contain acrylic or latex.
Are you allergic to latex?
YesNo
Are you allergic to acrylic?
YesNo
PLEASE CHECK ANY OF THE FOLLOWING THAT MAY APPLY TO YOU:
RELATING TO THE EYE
Eye surgeryEye illness or injuryDry eyesSeasonal allergiesEye InfectionPermanent eye make-upBlepharoplastyBlepharitis (inflammation of eyelids)Allergies to cyanoacrylate adhesives (i.e. surgical glue, nail glue, crazy glue)Hypersensitivity to formaldehyde ( aby-product released in cyanoacrylateadhesives)Retinoids used to treat acne and skin problems (such as accutane or retin a)
GENERALLY RELATING TO EYELASHES
Hormone imbalanceRecent severe illness or injuryPregnancy or recent childbirthNew prescriptions or recently prescribed oral contraceptivesTypes of medical conditions that may contribute to hair and eyelashloss: hyperthyroidism or hypothyroidism, alopecia areata, lupus, diabetesVitamin and mineral deficiencies that may contribute to hair and eyelash loss:A, F, B, Selenium, Zinc, IronTrichotillomania (hair pulling disorder)Medications that may contribute to hair or eyelash loss: chemotherapeutic agentsused in cancer treatment, Anticoagulants(blood thinners), beta blockers (used tocontrol blood pressure)
Other Medical Information
Client Name
First NameLast Name
Client Signature
Clear
Date
MonthDayYear
Date
Should be Empty:

Eyelash Extension Consultation Form