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Client Health History: Lash Extensions
First Name
Last Name
Address
Phone
Work Phone
Email
How should we contact you?
*
Required
Home/Cell Phone
Work Phone
Email
When is the best time to contact you?
*
Required
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)?
*
Required
Yes
No
Don't Know
Have you ever had a reaction to adhesive tape, topical creams, nail adhesives, or other topical products?
*
Required
Yes
No
Do you have any eye disease, condition or injury that has affected your hair/lash growth or loss?
*
Required
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:
*
Required
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?
*
Required
Yes
No
Details if applicable. Adverse reactions? If applicable
Do you wear contacts?
*
Required
Yes
No
Details if applicable. Adverse reactions? If applicable
Do you wear glasses?
*
Required
Yes
No
Details if applicable. Adverse reactions? If applicable
Have you ever had lash extensions?
*
Required
Yes
No
Details if applicable. Adverse reactions? If applicable
Have you ever had lash extensions removed?
*
Required
Yes
No
Details if applicable. Adverse reactions? If applicable
Have you ever used long lasting or waterproof cosmetics?
*
Required
Yes
No
Details if applicable. Adverse reactions? If applicable
Do you use Retin-A or Accutane?
*
Required
Yes
No
Details if applicable. Adverse reactions? If applicable
Do you go tanning (in salon, outdoor, or spray tan)?
*
Required
Yes
No
Details if applicable. Adverse reactions? If applicable
Have you had facial treatments?
*
Required
Yes
No
Details if applicable. Adverse reactions? If applicable
Have you ever had Botox®, Juvederm®, or any other injectables?
*
Required
Yes
No
Details if applicable. Adverse reactions? If applicable
Have you ever used Latisse® or any other lash growing product?
*
Required
Yes
No
Details if applicable. Adverse reactions? If applicable
Which side do you most often sleep on?
*
Required
Right
Left
Stomach
Back
How fast do you feel your hair grows?
*
Required
Fast
Slow
Normal Rate
Is there anything else we should know about?
Submit
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