INTAKE FORM | LASHES

ALL INFORMATION IS CONFIDENTIAL.

Name (required)

Date (required)

Address (required)

Email (required)

Cell Phone (required)

Whom may we thank for your referral?

Previous discomfort, stinging or adverse reactions. Please tick any that apply:

Any medications:

Other relevant information:

Have you had Lash or brow tinting, Lash Lifting, Lash perming, Eyelash extension or semi-permanent mascara applied previously? (required)

I request and consent to these procedures being carried out today without undergoing a sensitivity patch test. The sensitivity test, which if conducted may indicate my sensitivity / allergy to the products. I understand the contents of this form and take full responsibility for my actions, thus absolving all other parties of their responsibilities, if any, associated with the supply of the products and services(s).  (required)