Lash Client Consultation Form
All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.
E-mail
Medical Details*
Allergy to Latex, plasters, collagen, fish, acrylic nails Asthma Hayfever Claustrophobia Light Sensitive Smoker Eye Disorders Contact Lens wearer (must be removed for treatment) Taking HRT or steroids, thyroid medication Pregnant Oily skin & hair Chemotherapy within the last 6 months Have you worn lash extensions before? None of the above are relevant to me
Additional Medical Notes
The information that I have provided above is correct and true to the best of my knowledge, I give permission to my therapist to perform the patch test and understand that they will take every precaution to minimise or eliminate any negative reactions that may occur as a result of the treatment.*
Yes I agree
I give permission to my therapist to perform the eyelash extensions patch test on me. The therapist has explained to me the procedure and the products that I will be tested with during the patch test.*
Yes I agree
I understand that if my patch test shows a reaction, then I will inform my therapist immediately and I must not go ahead with the treatment. If my patch test result is clear, then I am safe to go ahead with my treatment.*
Yes I agree
I understand that despite a patch test showing a clear result, I could still react to a full set of lash extensions. On the rare occasion of this happening, I will not hold my therapist responsible and I will inform them ASAP. My therapist will assist me in this case and will offer a free removal (if safe to do so) and only after careful assessment of the extensions and eye area.*
Yes I agree
Privacy and Data Protection
Any data collected by The Lash and Nail Hideaway will be to ensure I can safely perform your treatment and to be able to contact you with regards to appointments. I need to store this data to comply with my public and products liability insurance and to be able to safely continue treatments and keep records of all products use should any issues/allergies/problems arise.
I will store your data either in a locked cabinet that only I have access to or (in the case of electronic formats) in secure encrypted locations accessible only through passwords or fingerprint id. I will not share your data with any third parties.
I will store this data for a period of 7 years beyond your last appointment with me to comply with my insurance company but it will be reviewed on a yearly basis where you can opt out. If you choose to opt out I will need to keep your existing data on file for insurance purposes. You can opt out at any time by contacting me in writing to The Lash and Nail Hideaway, 29 Stanton Road, Stoke on Trent, ST3 6DD If you decide to opt out and withdraw consent, I will no longer be able to perform any treatments on you.
Communication Preferences*
Text Email None
Photographs*
Yes No
Date*
Month Day Year
Client Signature*
Should be Empty: