Eyelash Extension Consent Form
Please fill out this form prior to your appointment.
Name
Email
Contact Number
Date of Your Appointment
Is this the first time you have had lash extensions?
Yes
No
Please indicate if you have worn any of the following lashes within the last 60 days:
Individual
Flare
Strip
Have Not Worn Lashes
Do you curl, perm, or tint your lashes?
Yes
No
Do you wear contacts?
Yes
No
Please list any eye drops or eye medication you are using:
Please check any of the following that applies to you:
Lasik Eye Surgery
Permanent Eye Surgery
Blephroplasty (eye lift)
Microdermabrasion
Alopecia
Thyroid Disease
Herypersensitivity to cyanoacrylate, formaldehyde, or certain adhesive/ glues
Recent Fever or Illness
Drugs that cause hair loss
Chemotherapeutic Agents
Allergic to Cyronacrylate
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