Client Intake & Consent — Lash and Brow Beauty Lounge

Client Profile

Let's start with your contact info.

Full Name *

Please enter your full name.

Address

City

State

Zip

Home/Cell Phone *

A phone number is required.

Email *

Please enter a valid email.

How should we contact you? (select all that apply) *

Home/Cell Phone Text Email

Please select at least one contact method.

How did you hear about us?

Health History

This helps us keep you safe during your appointment.

Please list any allergies you have (including cosmetics/ingredients)

Are you allergic to Acrylate/Cyanoacrylate (bonding agent)? *

Yes No Don't Know

Please select an answer.

Have you ever had a reaction to adhesive tape, topical creams, nail adhesives, or other topical products? *

Yes No

Please select an answer.

Do you have any eye disease, condition, or injury that has affected your hair/lash growth or loss? *

Yes No

Please select an answer.

Please list all current medications you are taking (including over-the-counter, herbs, vitamins, and supplements)

Any other health condition not listed?

A Few More Questions

Relevant to your hair growth and overall hair health. Answering "Yes" opens a spot for details.

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?

Please Initial Each Statement

Although every precaution will be taken to ensure your safety and wellbeing before, during, and after your lash extension application, please be aware of the following and initial each to confirm you understand.

Consent & Signature

Please read, then sign below.

Client Name (Printed) *

Please print your name.

Signature *

A signature is required.

Date

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We're so glad
you're here.

Client Profile

Health History

A Few More Questions

Please Initial Each Statement

Consent & Signature

Thank you!

This link isn't valid.

We're so gladyou're here.

Client Profile

Health History

A Few More Questions

Please Initial Each Statement

Consent & Signature

Thank you!

We're so glad
you're here.