Eyelash Extension Adhesive Issue Report Form
Please use this form to report any issues experienced with eyelash extension adhesive. Complete all fields to help us address your concern efficiently.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Product/Adhesive Name
*
Batch or Lot Number
Date of Purchase
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
When did the issue occur?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Describe the issue experienced
*
Observed symptoms or effects
*
Allergic reaction (e.g., redness, swelling)
Poor retention
Irritation or discomfort
Unusual odor or color
Other
Requested resolution
Replacement product
Refund
Technical support or advice
Other
Submit Report
Should be Empty: