Eyelash Intake Form

Contact Info

First Name (Required)
Last Name (Required)

Email (Required)
Phone (Required)

Address (Required)

Emergency Contact

First Name (Required)
Last Name (Required)

Relationship (Required)
Phone (Required)

Client History

Have you ever had eyelash extensions before? YesNo

If yes, what was your experience like?

Have you ever had extensions removed? YesNo

If yes, why?

Have you ever had permanent cosmetics applied to your eyes? YesNo

If yes, how long ago?

Do you normally spray tan? YesNo

Do you pick or pull at your lashes? YesNo

Which position do you sleep? Left, back, right or stomach? Do you wear a sleep mask?

Medical history

Do you have any allergies? Specifically, cyanoacrylate or latex? (Required) YesNo


Are you on any medication? Specifically, fertility drugs, hormones or birth control? YesNo



Any other info? Referred by someone? How did you hear about us?



Click here to view the agreement.