REGISTRATION AND HISTORY FORM
EYELASH EXTENSIONS.
Client Name:
Birth Date:
Address:
City:
State:
Zip:
Home #:
Business #:
Cell #:
Email:
Fax #:
Facebook Account:
Instagram Account:
How may we contact you regarding scheduled appointments or specials? Check all that apply:
Text Message
Email
Home Phone
Business Phone
Mobile
When do you prefer to be contacted?
Morning
Afternoon
Evenings
Sex:
Female
Male
Non-Binary
Other
Birthday:
Age:
Occupation:
Emergency Contact Name:
Relationship to You:
Emergency Contact Phone #:
How did you hear about us?
Name of the person that referred you:
1. Have you ever received eyelash extensions?
Yes
No
2. Have you had eyelash extensions removed?
Yes
No
3. Have you used under eye gel patches before?
Yes
No
4. Have you had permanent cosmetics applied to your eye area?
Yes
No
5. Do you wear glasses?
Yes
No
6. Do you wear any of the following:
Daily disposables contacts
Extended wear contacts
Permanent contacts
None of the above
7. Do you have a tendancy to rub your eyes or pull on your lashes?
Yes
No
8. Do you go tanning (in salon or outside) or get spray tans?
Yes
No
Sometimes
9. Are you pregnant?
Yes
No
If yes, which trimester are you in and have you discussed having this service with your doctor?
Which side do you sleep on?
Please select
Right
Left
Back
Stomach
Please select
*Please note that you may experience more eyelash extension loss on the side on which you sleep
11. Do you exercise?
No
Yes
Occasionally
12. Are you on a special diet?
Yes
No
*Please be advised that healthy natural eyelashes and hair growth require a diet rich in amino acids and protein. In addition, low-carb, low-protein and quick-results diets may affect a body's chemical balance, which can lead to loss of or damage to hair/natural eyelashes.
13. What brands and products are you currently using around your eyes?
14. Do you have allergies to any of the following?
Acrylates or cyanoacrylates
Nail adhesives
Tape or bandages
Long-lasting or waterproof cosmetics
Cosmetic, skin care products, topical creams or other topical products or ingredients
Any allergies not including those listed above?
15. Have you had or used any of the following in the last 4 weeks?
Eye surgery, wounds or infections
Exfoliating, skin-tightening, or skin-resurfacing facial treatments
Retin-A, Accutane or similar products
History of eye disease, condition, injury or surgery that affected your hair/natural eyelash growth or loss
16. How would describe your hair growth cycle as compared to others?
Slow
Fast
Unsure
17. Please note that medications used to treat the following conditions may cause hair/natural eyelash loss. If you are on medications to treat any of the following, please mark them below:
Acne
Allergies (when treated with non-steroidal anti-inflammatory drugs (NSAIDS))
Anticoagulants
Autoimmune diseases
Birth Control*
Convulsions/Epilepsy
Depression
Diet/Weight loss
Dry eye syndrome
Fungus
Glaucoma
High blood pressure
High cholesterol
Hormone imbalance, hormone therapy*
Inflammation (when treated with NSAIDS)
Parkinson's disease
Thyroid disease
Ulcers
Cancer
*Although these are not medical conditions, birth control and hormone therapy may result in the thinning or loss of natural eyelashes.
18. List all current medications, herbal supplements and vitamins:
19. Please mark all conditions that apply:
Alopecia
Asthma
Autoimmune diseases (Crohn's disease, arthritis, lupus, ulcerative colitis, etc.)
Back pain
Bel's Palsy
Blepharitis
Bronchitis (chronic)
Claustrophobia
Cold sore
Conjunctivitis (pink eye)
Diabetes
Diabetic retinopathy
Dry eye syndrome
Eye sties or sores
Heavy eyelid
Hormonal disorders or changes
Leamy eye or excessive tearing
Migraines
Ocular rosacea
Overactive bladder
Rosacea
Seizure disorder
Sensitive eyes
Sensitivity to light
Sinus problems
Stress
Stroke
Tendency of redness, rashes or hives
Thyroid disease
Trichotillomania (hair or eyelash pulling)
Other:
Additional Comments
Signature
Clear
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