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EYE LASH EXTENSION CONSENT FORM
Please fill this form out prior to your appointment.
Name
*
First
Last
Email
*
Contact Number
*
Date of your appointment
*
MM
/
DD
/
YYYY
Is this the first time you have had lash extensions?
Yes
No
Please indicate if you have worn within the last 60 days any of the following types of lashes:
Individual
Strip
Flare
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 might apply to you:
Lasik Eye Surgery
Permanent Eye Surgery
Blephroplasty (eye lift)
Microdermabrasion
Alopecia
Thyroid disease
Hypersensitivity to cyanoacrylate, formaldehyde or certain adhesives/glues
Recent fever or illness
Drugs that cause hair loss
Chemotherapeutic agents
Allergic to cyronacrylate
Comments or Questions
