Name *

First Name

Last Name

DOB *

MM

DD

YYYY

Phone *

(###)

###

####

Medical History

Eye infections (e.g. conjunctivitis, styes)

Blepharitis or dry eyes

Allergies (latex, adhesives, cosmetics)

Recent eye surgery (within 6 months)

Contact lenses

Skin conditions (eczema, psoriasis, etc.)

Sensitivity to touch, steam, or adhesives

Pregnancy or nursing

Have you had lash extensions before? *

Yes

No

Have you ever had a reaction to lash extensions? *

Yes

No

Do you wear mascara or other eye makeup daily? *

Yes

No

Length: *

Natural

Medium

Long

Curl: *

Natural

Dramatic

Volume: *

Classic

Hybrid

Volume

Mega Volume

*

I understand that lash extensions involve the application of synthetic fibers to my natural lashes using adhesive.

*

I acknowledge that while rare, there are potential risks including but not limited to eye irritation, allergic reactions, and damage to natural lashes.

*

I agree to follow the aftercare instructions provided to me to ensure the longevity and safety of the extensions.

*

I release the technician and salon from any liability for damages or reactions that may result from the service.

*

I understand that fills are recommended every 2-3 weeks to maintain the appearance of my lash extensions.

*

I agree to inform the technician of any discomfort during the procedure.

I consent to before-and-after photos for documentation and marketing purposes *

Yes

No

*

I have read and understood the above information. All questions have been answered to my satisfaction.

Digital Signature *

First Name

Last Name

Date *

MM

DD

YYYY