CONSENT TO APPLICATION OF LASH EXTENSION PROCEDURE
Please take a moment to complete our consent form. By submitting the form below you agree to knowingly and willingly consenting to have Lash Extension service.
Please fill this form out on the date of your appointment. Thank you.
How should we contact you? (check one)
When is the best time to contact you? (check one)
Surgery less than 4 months (must wait 4 weeks post-op exam f0r medical consent)
Blepharoplasty (must wait 6 months post-op for medical consent)
Please list any allergies you have (including cosmetics ingredients):
Are you allergic to Acrylate/Cyanoacrylate (bonding agent)?
Have you ever had a reaction to adhesive tape, tropical creams, nail adhesives, or other tropical products?
Do you have any eye disease, condition or injury that has effected your hair/lash growth or loss?
Chemotherapy Treatments within the last 6 months?
Are you taking any Thyroid Medications?
Extremely oily skin and hair?
Please list all current medications you are taking (including over-the-counter herbs, vitamins, and supplements):
These questions are relevant to your hair growth, and overall hair health. Please answer as truthfully as possible.
Are you pregnant or nursing?
Do you wear contacts?
Do you wear glasses?
Do you use Retina or Accutane?
Have you had a facial treatment in the last month?
Do you go tanning (in salon, outdoor, or spray tan)?
Have you ever had Botox, Juvederm, or any other injectables?
Have you ever used Latisse or any other lash growing products?
Do you habitually rub, pull, or pick your lashes for any reason?
Are you having lash extensions applied for:
Which side do you most often sleep on?
How fast do you feel your hair grows?
Is there anything else we should know about? Please list below:
Have you ever used long lasting or waterproof cosmetics?
Have you ever had lash extensions?
Have you ever had lash extensions removed?