Name *

First Name

Last Name

Today's Date *

MM

DD

YYYY

Phone Number *

(###)

###

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Date of Birth *

MM

DD

YYYY

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact *

(###)

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𝗟𝗮𝘀𝗵 𝗟𝗶𝗳𝘁 𝗮𝗻𝗱 𝗧𝗶𝗻𝘁 𝗖𝗼𝗻𝘁𝗿𝗮𝗶𝗻𝗱𝗶𝗰𝗮𝘁𝗶𝗼𝗻𝘀:

Dry Eye Syndrome

Ocular Rosacea

Sjorgen's Syndrome

Chemotherapy

History Of Eye infection

Sjorgen's Syndrome

𝗕𝗿𝗼𝘄 𝗟𝗮𝗺𝗶𝗻𝗮𝘁𝗶𝗼𝗻 𝗮𝗻𝗱 𝗧𝗶𝗻𝘁 𝗖𝗼𝗻𝘁𝗿𝗮𝗶𝗻𝗱𝗶𝗰𝗮𝘁𝗶𝗼𝗻𝘀:

Alopecia

Wounds In Treatment Area

Recent Facial Treatment (chemical peels/laser)

Psoriasis

History Of Eye infection

Super Sensitive Skin

Eczema

Sunburn

Retinol, AHA, BHA etc.

Do you have any know allergies to adhesives, fumes or removers? *

No

Yes

Have you had previous allergies/sensitivities to lash lift, tint or brow lamination products? *

No

Yes

Are you pregnant or breastfeeding? *

No

Yes

Do you wear contacts? *

No

Yes

Do you use eye drops of any kind? *

No

Yes

Do you use oil-containing sunscreen or moisturizer around the eyes? *

No

Yes

Have you recently had lash extensions/lash lift or brow lamination? *

No

Yes

Have you recently had any semi-permanent makeup procedures done? *

ie. micro-blading, nano/powder brows, tattoo liner.

No

Yes

I consent to have my eyes closed and covered for the duration of the 45-90 minute procedure.

No

Yes