Lash Extension Intake Form

Lash Extension Intake Form
Name

First Name Last Name
Email
example@example.com
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Birth Date

Month Day Year
Occupation
Emergency Contact
Emergency Contact Phone Number

Area Code Phone Number
Have you ever received eyelash extensions?

Yes No
Have you ever had eyelash extensions removed?

Yes No
Have you ever used under eye gel patches?

Yes No
Have you ever had permenant cosmetics before?

Yes No
Do you wear glasses?

Yes No
Do you wear contact lenses?

Yes No
Do you tend to rub your eyes or pull on your eyelashes?

Yes No
Have you taken Retin-A or Renova in the past 3 months?

Yes No
Do you go tanning, or get spray tans?

Yes No
Are you pregnant?

Yes No
Are you currently under a physicians care for any skin condition?

Yes No
Have you ever had an adverse reaction to any cosmetic product?

Yes No
Do you exercise?

Yes No
Are you on a special diet?

Yes No
*Please note*

A healthy lash cycle requires a diet rich in amino acids and protein. In addition, low carb, low protein, and quick result diets may affect a body's chemical balance, which may lead to loss of or damage to hair/ natural lashes.

A natural lash cycle sheds 2-5 lashes per eye, per day. When the natural lash sheds it will take the extension with it, therefore we recommend a refill every 2 weeks.

Only oil free products are safe for your lash extensions, and waterproof cosmetics are not compatible with extensions, so please read any cosmetic/ skin care labels. Xtreme Lashes brand products are safe and recommended.

Please make sure you arrive to every appointment with CLEAN LASHES. Extension services are time based so extensive makeup removal limits the time available for lashing. Makeup residue will also create a barrier on your lashes and not allow your extensions to attatch properly. If extensive cleansing is necessary, an additional cleaning fee will be applied.

I do not work on non Xtreme Lashes. If you have a previous set from another lash stylist who is not Xtreme Lashes certifed, your set may need to be removed. If you visit another lash stylist for a refill after seeing me I reserve the right to remove you as a client for sanitation liability concerns.

Please do not bring any children or guests to any lash appiontment.

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