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Eyelash Extentions Intake Form

Eyelash Extentions Intake Form

How did you hear about us?
Do you wear contact lenses?
Have you had any eyelash extensions before?
Are you pregnant?
Do you perm or tint your lashes?
Please chek off any that may apply to you

If at any time I am uncomfortable with the eyelash extensions procedure, I will inform the stylist and she will gladly rectify the problem, including ending the session if necessary. If the stylist is uncomfortable with applying eyelash extensions to my natural lashes she will carefully explain her concerns and end the session.


By signing below, I agree that all risks have been made clear to me. I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the eyes from treatments received. The treatments I receive here are voluntary and I release this skin care professional and business from liability and assume full responsibility thereof. *

Thanks for submitting!

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