Eyelash Extension

Appointment Date

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

Format: (000) 000-0000.

Email

example@example.com

Occasionally I may send out emails or newsletters about upcoming discounts, promotions, contests, company information etc. If you would like to be added to the subscriber list please check “Yes” below. If you would like to opt out please check “No”.

Have you had eyelash extensions applied before ?

If yes, why did you remove them?

Do you wear glasses?

Do you have frequent eye irritation, itching, or watery eyes?

Have you had eye surgery in the last six months?

*Eyelash extensions require medical tape and adhesives that may contain acrylic or latex.

Are you allergic to latex?

Are you allergic to acrylic?

PLEASE CHECK ANY OF THE FOLLOWING THAT MAY APPLY TO YOU:

RELATING TO THE EYE

GENERALLY RELATING TO EYELASHES

Other Medical Information

Client Name

First NameLast Name

Client Signature

Date

Eyelash Extension Consultation Form