Skin Care Consultation Form

Lash Extension Consultation Form
Name *

First Name Last Name
Today's Date *
Phone Number *

Area Code Phone Number
E-mail *
example@example.com

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Birthday
How did you hear about me?

Instagram Facebook Referral Website / Online Search Other
If Referral, please list name
If Other, please let me know
Health Information
Do you have any allergies? (including cosmetics/ingredients) *

Yes No
If yes, please list allergies below
Are you allergic to Acrylate/Cyanoacrylate (bonding agent)? *

Yes No Don't know
Have you ever had a reaction to adhesive tape, topical creams, nail adhesives, or other topical products? *

Yes No
Do you have any eye disease, condition, or injury that has affected your lash growth/loss? *

Yes No
(optional) Please list any medications you are currently taking (including over the counter herbs, vitamins, and supplements:
Do you have any other health conditions?
These questions are relevant to your hair growth, and overall hair health. Please answer as fully as possible.
Have you ever had any of these conditions?

Alopecia Hormonal Imbalance Cancer/chemo Thyroid Disease Blepharitis Conjuntivitus Recent Eye Surgery Dry eye Watery eyes Sensitive eyes Sensitivity to light Claustrophobia
Are you pregnant or nursing?

Yes No
Do you wear contacts or glasses?

Contacts Glasses Both Neither
Have you had facial treatments?

Yes No
Have you received any Botox, Juvederm, or other dermal fillers?

Yes No
Do you use any lash growth products or serums?

Yes No
If yes, what product?
What side do you most often sleep on?

Left Right Stomach Back
How fast do you feel your hair grows?

Fast Normal Slow
Is there anything else I should know?
General Liability Release
I understand that eyelash extensions require ongoing maintenance and that fill fees are based on length of appointment and time in between lash fills. If I wait too long between fills, I may need to pay for a new full set. If I no longer wish to wear the eyelash extensions, my Lash Artist will remove them and I will not try to remove them myself and there may be a fee for removal of the eyelash extensions. *

I agree
I understand that this is a semi-permanent procedure, as my natural lashes will continue to grow and fall out normally, making Lash Fill Appointments necessary to maintain the original look achieved by replacing lashes that have fallen out. Most clients require a fill appointment every 2-3 weeks. *

I agree
Sleeping on my face, extreme weather changes, steam, sauna, wearing makeup/mascara, and other activities may damage the adhesive or crimp the extensions and may require more frequent refills. I reviewed and understand the aftercare instructions and will do my part to help maintain my eyelash extensions. *

I agree
I will seek medical care (at my own expense) and contact Studio Kalon LLC immediately if any allergic or adverse reaction occurs. All of my questions were answered and I understand the procedure and risks. *

I agree
I grant permission to use my before and after photos for marketing or examples of my Lash Artists work. (Before and after photos are a permanent part of the Lash Artist’s records. You may opt out of marketing purposes)

I agree
I release Studio Kalon LLC and Lash Extension Artist from any and all liability associated with this procedure (which will be performed with the utmost attention to safety and proper application using tools and products that the Lash Artist has been trained to use. This procedure has many variables due to lifestyle, moisture, weather, extreme temperatures, natural eyelash shedding, and other factors. The Lash Artist will assess and decide if I am a candidate for this service to the best of their ability. No guarantees are made or implied. *

I agree
Reservation & Cancellation Policy for all current and future appointments: a valid credit card is required for all appointments. Please do not forget to confirm your appointment when you receive your reminder from Square. In the event of cancellations received less than 24 hours prior to an appointment, a cancellation fee equal to 50% of the reserved service booking will incur. No Shows will be charged 100%. *

I understand the reservation and cancellation policies at Studio Kalon LLC and consent to my credit card on file being charged if I fail to give 24 hour notice for appointments scheduled.
By signing below, I verify that I have read and understand the above statements and agree to them. *

Yes
Signature *

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Lash Extension Consultation Form

Health Information