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Client Health History: Lash Extensions
First Name
Last Name
Address
Phone
Work Phone
Email
How should we contact you?
Home/Cell Phone
Work Phone
Email
When is the best time to contact you?
Morning
Daytime
Evening
Emergency contact name & phone
Emergency contact Relationship
Please list any allergies you have (including cosmetics/ingredients)
Are you allergic to Acrylate/Cyanocarylate (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 hair/lash growth or loss?
Yes
No
Please list all current medications you are taking (including over-the-counter herbs, vitamins and supplements):
Have you ever had any of these conditions? Please select from the following:
Alopecia
Asthma
Back pain or back injury
Bell's Palsy
Blepharitis
Claustrophobia
Cold Sores
Conjunctivity (pink eye)
Diabetes
Dry Eye Syndrome
Eye Sties or Sores
Herpes of the Eye
Intense Stress
Leamy Eye
Light Sensitivity
Migraines
Ocular Rosacea
Rosacea
Sensitive Eyes
Stroke/TIA
Thyroid Disease
Trichotillomania
Recent Eye Surgery
Current Eye Irritation
List any health conditions not listed
These questions are relevant to your hair growth, and overall hair health. Please answer as fully as possible.
Are you pregnant or nursing?
Yes
No
Details if applicable. Adverse reactions? If applicable
Do you wear contacts?
Yes
No
Details if applicable. Adverse reactions? If applicable
Do you wear glasses?
Yes
No
Details if applicable. Adverse reactions? If applicable
Have you ever had lash extensions?
Yes
No
Details if applicable. Adverse reactions? If applicable
Have you ever had lash extensions removed?
Yes
No
Details if applicable. Adverse reactions? If applicable
Have you ever used long lasting or waterproof cosmetics?
Yes
No
Details if applicable. Adverse reactions? If applicable
Do you use Retin-A or Accutane?
Yes
No
Details if applicable. Adverse reactions? If applicable
Do you go tanning (in salon, outdoor, or spray tan)?
Yes
No
Details if applicable. Adverse reactions? If applicable
Have you had facial treatments?
Yes
No
Details if applicable. Adverse reactions? If applicable
Have you ever had Botox®, Juvederm®, or any other injectables?
Yes
No
Details if applicable. Adverse reactions? If applicable
Have you ever used Latisse® or any other lash growing product?
Yes
No
Details if applicable. Adverse reactions? If applicable
Which side do you most often sleep on?
Right
Left
Stomach
Back
How fast do you feel your hair grows?
Fast
Slow
Normal Rate
Is there anything else we should know about?
Submit
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