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Client Profile
CLIENT INFORMATION
*
Indicates required field
Name
*
First
Last
Date
*
Date of Birth
*
Email
*
Phone Number
*
Occupation
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Referred By
*
Contact Preference
*
Text
Email
Call
ALLERGIES
Select All That Apply
*
Cyanoacrylate
Nail Adhesives
Acrylic Nails
Band-Aids/Latex
Cosmetics
Other
None
Do you have any other conditions or concerns that we should be aware of?
*
PREVIOUS TREATMENTS
Select All That Apply
*
Eyelash Extensions
Eyelash Extension Removal
Eyelash Perm/Lift
Permanent Makeup
Eyelash Tint
None
Was your previous treatment experience positive? If not, please explain.
*
LIFESTYLE
Mascara Applications
*
N/A
1 time per week.
2 times per week.
3 times per week.
4 times per week.
5 times per week.
6 times per week.
7 times per week.
Eyeliner Applications
*
N/A
1 time per week.
2 times per week.
3 times per week.
4 times per week.
5 times per week.
6 times per week.
7 times per week.
Eye Cream Applications
*
N/A
1 time per week.
2 times per week.
3 times per week.
4 times per week.
5 times per week.
6 times per week.
7 times per week.
Hot Yoga
*
N/A
1 time per week.
2 times per week.
3 times per week.
4 times per week.
5 times per week.
6 times per week.
7 times per week.
Swimming
*
N/A
1 time per week.
2 times per week.
3 times per week.
4 times per week.
5 times per week.
6 times per week.
7 times per week.
Steam Room/Suana
*
N/A
1 time per week.
2 times per week.
3 times per week.
4 times per week.
5 times per week.
6 times per week.
7 times per week.
What side do you sleep on?
*
Right
Left
Face
All over the place
Do you pick/pull/tug on your lashes or eyebrows?
*
Yes
No
Conditions
Products
If you use any products, list them.
Choose all that apply.
*
Sensitive Eyes
Watery Eyes
Itchy Eyes
Eye Discharge
Glaucoma
Blepharitis
Eye Surgery
Conjunctivitis
Stye
Alopecia
Thyroid Disease
Trichotillomania
Any of conditions you feel we should know about.
*
Eye Make Up Remover
*
Mascara
*
Lash Growth Serum
*
Face Cleanser
*
Do you use a lash curler?
*
Yes
Nope
Never heard of it
Eye Liner
*
Eye Cream
*
Moisturizer
*
List any previous product reactions.
*
What is your skin type?
*
Dry
Oily
Normal
Sensitive
Do you use any of the following?
Contact Lenses.
*
Hard
Soft
Extended wear
No Contact lenses
Eye drops.
*
Over the counter
Rx
None
Glasses.
*
Daily
Occasionally
No
Submit
Home
About Me
Lash Menu
Lash Menu
Gallery
Lash 101
Book Me
Policies
Forms
Client Profile
Consent for Extensions
Consent to Tint/Curl
Contact Me
UA-109902978-1
