Name *

First Name

Last Name

Birth Date *

MM

DD

YYYY

Phone *

(###)

###

####

Do you wear eye glasses daily? *

Yes

No

Do you wear makeup daily? *

Mascara

Eyeshadow

Eyeliner

None

What is your skin type? *

Dry

Oily

Combo

Possible Contraindications We would love for you to enjoy eyelash extensions as much as we do. But there are certain situations in which the treatment shouldn’t be performed and therefore we won’t be able to do the treatment. These are called “contraindications”. Please check any contraindications you may have: *

Contagious or eye infection disorder E.g. Pink eye (Conjunctivitis)

Hypersensitive Skin

Stye (a tender red bump on the edge of the eyelid filled with puss caused by staphylococcus bacteria)

Swelling of the eyes

Chemotherapy (lashes may not last due to loss of hair)

Cuts or open wounds in the area

Epilepsy (a common condition that affects the brain and causes frequent seizures)

Claustrophobia

Semi-Permanent makeup E.g. eyeliner (healed after 4 weeks)

Laser eye surgery (must be healed for a least a week)

None

Do you give us permission to use your photos for our Instagram. We may keep your photos for our private records to keep track of your lash health. *

Yes - eyes only

Yes - my whole face is fine

Yes - for my client records only

No pictures please

Today's Date *

MM

DD

YYYY