Eyelash Service Questionnaire

Name*
First Last
Birthdate*
Month
Day
Year
Address*
Street Address Address Line 2 City State ZIP Code
Best phone number for you?*
Email*
Enter Email Confirm Email
Emergency Contact*
First Last
Emergency Contact Phone*
Who referred you?
First Last
What is the reason for your visit today?*
How may we contact you? Select all that apply.*
- Email
- Text Message
- Phone Call
Are you under a Physician's care? If yes, please describe below.*
- No
- Yes
If Yes checked above, please describe here.
Please list any allergies:
Do you wear contact lenses?*
- No
- Yes
Have you worn eyelash extensions before? If yes, please state how long ago and your experience below.*
- No
- Yes
If yes, please describe here.
Are you affected by any of the following? Check all that apply.
- Current use of eyedrops, prescription or over-the-counter
- Current use of any oil containing products around the eye area
- Current allergies or sensitivities to instruments, fumes, tape, cleaners, eye gel pads, adhesives, or removers that could cause my eyes to water and blink in excess
- History of claustrophobia
- History of recurrent eye or tear duct infections
- History of dry eyes or Sjorgen's Syndrome
- Recent history of chemotherapy
- Other medical conditions which would prohibit or compromise placement and retention of eyelash extensions
- Other, please describe below.
Please describe below.*
I agree to the following eyelash extension post-op and maintenance instructions:
- No waterproof mascara
- No prescription or over-the-counter eye drops
- No oil based products around the eye area
- Allow 24 hours before getting lashes wet
- No tinting or perming of eyelash extensions
- No continuous pulling or rubbing of the synthetic lashes
I understand the information here is to aid the lash artist and it is not a substitute for medical care. I understand the questions and have answered them honestly and correctly.*
Acknowledge
I understand the information here is to aid the lash artist and it is not a substitute for medical care. I understand the questions and have answered them honestly and correctly.
I understand that Angelique Swann Esthetics & Wellness Solutions and staff do not diagnose illness, disease, or any other physical or mental disorder. I accept full responsibility of the use of Angelique Swann Esthetics & Wellness Solutions at my own risk, and to not hold Angelique Swann Skincare & Beauty Solutions or staff liable for loss, damage or injury.*
Acknowledge
I understand that results are personable and not guaranteed.*
Acknowledge
I confirm that to the best of my knowledge that the answers given on client consultation form are correct and that I have not withheld any information that maybe relevant to my treatment at Angelique Swann Esthetics & Wellness Solutions.*
Acknowledge
I understand that I must provide at least 24 hours advance notice for the cancellation of an appointment.*
Acknowledge
Angelique Swann Esthetics & Wellness Solutions has a strict 24-hour cancellation policy. Your appointment time is reserved exclusively for you. Communication is crucial if you need to cancel or reschedule your appointment. In the event of a late cancellation the fee is the cost of your appointment or $50.00, whichever is less. If appointment is cancelled same day or no show, the fee is 100% of scheduled service. PLEASE NOTE: Saturday appointments now require a 3 day (72 hour) notice to reschedule or cancel. An invoice will be sent, which is due upon receipt. If I am able to replace appointment with a client on wait list, I am happy to waive the fee.*
Acknowledge
I agree to have Angelique Swann Esthetics & Wellness Solutions eyelash extensions applied to my natural eyelashes and/or removed and retouched. By signing this agreement, I consent to the placement and removal of eyelash extensions by the certified eyelash extension professional.*
Acknowledge
I understand there are risks associated with having artificial eyelashes and eyelash extensions applied to or removed from my natural eyelashes. I further understand that as part of the procedure, eye irritation, eye pain, eye itching, discomfort, and in rare cases, eye infection or blindness can occur. I agree that if I experience any of these medical conditions with my lashes I will contact the certified eyelash extension professional and have the eyelashes removed immediately and consult a physician at my own expense. I understand that even though the certified eyelash extension professional applies or removes the eyelash extensions using the proper technique, the instruments, tapes, cleaners, eye gel pads, adhesives, and removers used may irritate my eyes or require a physician’s follow-up care and subsequent removal of the eyelash extensions.*
Acknowledge
I understand and agree to the care instructions provided by the certified eyelash extension professional for the use and care of my eyelash extensions. I realize and accept the consequences of failure to adhere to these instructions may cause the eyelash extensions to fall out, damage the extensions and/or decrease the time the lashes will last.*
Acknowledge
I understand and consent to having my eyes closed and covered for the duration of the 60-120 minute procedure.*
Acknowledge
I understand and consent to having my eyes closed and covered for the duration of the 60-120 minute procedure.
Yes! I would love to be added to Angelique Swann Esthetics & Wellness Solutions monthly newsletter for relevant information, timely topics, and special savings offers to enhance your life.*
Acknowledge
Please note any additional information that may be of importance to your Licensed Esthetician regarding the spa treatment you may be receiving.
Signature (your name submitted below will be considered your electronic signature)*
First Last
Date Signed*
Month
Day
Year