New Lash Client Intake Questionnaire

Welcome to LM Lash Artistry!
1. Please fill in your Contact Information Below. *
2. Are you currently wearing eyelash extensions ? *
3. If yes, were they applied by LM Lash Artistry or elsewhere?
4. Have you had a Lash Lift & Tint in the last 8 weeks? if so additional time may be required and charges will be applied. *
5. Are you 18 years of age or older? *
6. What is your preferred method of communication? *
7. Are you pregnant? *
8. Do you suffer from any allergies to Medical Tapes, Adhesives, Band-Aids, Acrylics, Cyanoacrylates, or Collagen? *
9. If yes, please describe: (If no, please skip)
10. Are you currently taking any hormone replacement medications including Thyroid Medication? *
11. Are you currently taking Accutane? *
12. Do you suffer from any type of hair loss? *
13. Do you pull or pick your eyelashes? *
14. Do you wear contact lenses? If so, you may choose to remove them prior to the application however it is not required. *
15. Do you ever experience Vertigo or Dizziness? *
16. Do you suffer from seizures or epilepsy? *
17. Have you had laser eye therapy or chemotherapy in the last 6 weeks? *
18. Is this your first time applying semi-permanent eyelash extensions? *
19. Do you have any concerns or questions prior to proceeding? *
Terms & Conditions
I understand that this procedure requires single synthetic eyelashes to be adhered to my own natural eyelashes. I understand that it is my personal responsibility to keep my eyes closed and be still during the entire procedure, until my technician addresses me to open my eyes. I understand that some risks of this procedure may be but not limited to eye redness and irritation. I understand that this appointment is geared towards rest & relaxation and children & pets are not permitted to be unsupervised in the salon. Please arrange childcare for your children unless they are old enough to wait in the waiting room unattended. Infants in car seats are also not permitted. This is for the health and safety of your children as we do use very sharp tools, chemicals and professional adhesives for the procedures. I also agree to refrain from using my cell phone during the procedure. I understand that I am to follow the lash care guidelines in order to maintain the life of these extensions and that if I fail to care for my lashes correctly I will be solely responsible for the damage caused to my natural eyelashes & skin. I agree that by reading and accepting this consent form, I release LM Lash Artistry and my eyelash extension technician from any claims or damages of any nature. I understand this service is 100% non-refundable due to the intimate nature of the application, and should I have any adverse reactions to the products or the procedure itself that no refunds will be given. I understand the risks and contraindications and would like to proceed. I understand that if I no-show for any future appointments I will be billed the full amount of the service missed. Late cancellations (less than 24 hr notice) will be charged 50% of the service missed.
I agree to the above terms and conditions. *
Parent/ Guardian, I agree to the terms and give my consent.