Eyelash Extension Client Intake Information
Client Name: ________________________________________________ Date: _______
Cell Phone Number: ______________________ Home: ________________________
How do you preferred to be reached?
Cell Home Email
Please Note: If you’ve had any of the following, this may compromise your ability to successfully wear lashes. Please check all that apply.
Contacts: Yes No
Allergies: Yes No
Alopecia: Yes No
Cancer: Yes No
Demodex for Liculorum: Yes No
Non-functioning tear ducts: Yes No
Lasik Surgery: Yes No
If so when? ______________________
- Have you received any eye surgeries or procedures (such as Lasik, an eye lift, permanent make-up, etc.):
Yes No If so, when: ____________________________
- Have you received a chemical peel or microdermabrasion treatment within the last 14 days?
- Are you currently using any of these medications:
Retin A Accutane
Vitamin A Blood Thinners
Differin Any Acne Medication
Please sign that you are aware
-Specialist has sanitized hands and implements.
-I assume full responsibility for myself and anybody in my care.
-I hold harmless Minkys by Extend Your Lash and all specialists associated, with respect to any and all injury, loss, or damage to person or personal property to the fullest extent of the law.
-I am not sensitive to acrylic fingernails or nail polish.
-I have notified my eyelash specialist of any and all health complications that I may have, and have provided said specialist with a list of my medications and allergies.
-I will give a minimum of 24 hours notice for a cancellation so that specialist can book another client for the time that was reserved.
-If I don’t not give 24 hours notice for a cancellation or appointment change, I will pay a fee of $35 to compensate for the specialist’s time.
-If I do not call to cancel an appointment and fail to show up to said appointment, then I am aware that I will be charged a cost of session fee upon my next visit.
-I am aware that on rare occasions, an allergy may occur between myself and the lash adhesive, where irritation, redness, or swelling may take place. If this should happen, I will not hold the specialist who applied my eyelash extensions or Minkys by Extend Your Lash liable.
-I have reviewed my original Client Intake Information Form and confirm that I have disclosed all accurate information to the best of my ability. I also have the right to request a copy of my Client Awareness Form, as well as a copy of my After Care Form. For any and every additional eyelash extension appointment I will review these forms and either confirm that the information is still up to date, or I will let my esthetician aware of any changes.
-I understand that to insure the longest lasting lashes possible, I should avoid rubbing and pulling on my eyelashes.
-I understand that mascara of any kind could break down the lash adhesive, resulting in a shortened lash life.
-I am aware that the lash adhesive needs at least 6-8 hours to fully cure and that I MUST avoid water, steam, tears, eye drops, or any wet products in, on, or around my eyes and lashes during this time period. I am fully aware that moisture on my lashes within 6-8 hours after my eyelash extensions have been applied may result in irritation to my eyes or eyelids, and could compromise the appearance and/or the longevity of the lashes.
-I understand that any products, such as make-up removers, moisturizers, make-up, or eye creams, on or around my eyelash extensions may compromise the longevity of the lashes.
-If I fail to follow these after care instructions, I will not render my eyelash technician responsible for any dissatisfactory results.
Print Full Name - Sign - Date