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EYELASH EXTENSION

INTAKE & CONSENT FORM

Today's Date: May 20, 2025

First Client's Name
First Name*
Last Name*
Phone*
First Client's Date of Birth*
Date of Birth
First Client's Information
Job role:
How did you FIRST hear about Bella Lash Brow?*
Have you had lash extensions before?*
No
Yes
If yes, where have you had them applied (most recent place if more than one)?
Within the last 3 months, have you had any of the following types of lashes? *
individual
strip
cluster
Other
None of the above
If Other, please list:
Are you having your lashes done for:*
If special occasion, please list:
Do you normally wear contact lenses?*
No
Yes
Do you normally wear glasses?*
No
Yes
Do you have or are you being treated for any eye illness or injury?*
No
Yes
Please check if any of the following apply to you:
Laser Eye Surgery
Epilepsy
Dry Eye syndrome
Conjunctivitis
Psoriasis
Trichotillomania
Alopecia
Cataract
Diabetic Retinopathy
Glaucoma
Herpes Simplex
Currently pregnant
Any other known medical conditions which may affect the suitability for an eyelash treatment?

I understand that there has been no patch test carried out 24hrs prior to treatment. I consent to the treatment being performed. I also understand the risks associated with having artificial eyelashes applied to and/or removed from my existing eyelashes and also understand the importance of following the aftercare and maintenance guide (given after treatment) which will determine how long the lashes last and reduce the chance of any risks.

(*Please note that your treatment may take up to 2hrs so please head to the bathroom if you need to now!)



If yes please state:
First Client's Signature*
Second Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Second Client's Information
Job role:
How did you FIRST hear about Bella Lash Brow?*
Have you had lash extensions before?*
No
Yes
If yes, where have you had them applied (most recent place if more than one)?
Within the last 3 months, have you had any of the following types of lashes? *
individual
strip
cluster
Other
None of the above
If Other, please list:
Are you having your lashes done for:*
If special occasion, please list:
Do you normally wear contact lenses?*
No
Yes
Do you normally wear glasses?*
No
Yes
Do you have or are you being treated for any eye illness or injury?*
No
Yes
Please check if any of the following apply to you:
Laser Eye Surgery
Epilepsy
Dry Eye syndrome
Conjunctivitis
Psoriasis
Trichotillomania
Alopecia
Cataract
Diabetic Retinopathy
Glaucoma
Herpes Simplex
Currently pregnant
Any other known medical conditions which may affect the suitability for an eyelash treatment?

I understand that there has been no patch test carried out 24hrs prior to treatment. I consent to the treatment being performed. I also understand the risks associated with having artificial eyelashes applied to and/or removed from my existing eyelashes and also understand the importance of following the aftercare and maintenance guide (given after treatment) which will determine how long the lashes last and reduce the chance of any risks.

(*Please note that your treatment may take up to 2hrs so please head to the bathroom if you need to now!)



If yes please state:
Third Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Third Client's Information
Job role:
How did you FIRST hear about Bella Lash Brow?*
Have you had lash extensions before?*
No
Yes
If yes, where have you had them applied (most recent place if more than one)?
Within the last 3 months, have you had any of the following types of lashes? *
individual
strip
cluster
Other
None of the above
If Other, please list:
Are you having your lashes done for:*
If special occasion, please list:
Do you normally wear contact lenses?*
No
Yes
Do you normally wear glasses?*
No
Yes
Do you have or are you being treated for any eye illness or injury?*
No
Yes
Please check if any of the following apply to you:
Laser Eye Surgery
Epilepsy
Dry Eye syndrome
Conjunctivitis
Psoriasis
Trichotillomania
Alopecia
Cataract
Diabetic Retinopathy
Glaucoma
Herpes Simplex
Currently pregnant
Any other known medical conditions which may affect the suitability for an eyelash treatment?

I understand that there has been no patch test carried out 24hrs prior to treatment. I consent to the treatment being performed. I also understand the risks associated with having artificial eyelashes applied to and/or removed from my existing eyelashes and also understand the importance of following the aftercare and maintenance guide (given after treatment) which will determine how long the lashes last and reduce the chance of any risks.

(*Please note that your treatment may take up to 2hrs so please head to the bathroom if you need to now!)



If yes please state:
Fourth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Fourth Client's Information
Job role:
How did you FIRST hear about Bella Lash Brow?*
Have you had lash extensions before?*
No
Yes
If yes, where have you had them applied (most recent place if more than one)?
Within the last 3 months, have you had any of the following types of lashes? *
individual
strip
cluster
Other
None of the above
If Other, please list:
Are you having your lashes done for:*
If special occasion, please list:
Do you normally wear contact lenses?*
No
Yes
Do you normally wear glasses?*
No
Yes
Do you have or are you being treated for any eye illness or injury?*
No
Yes
Please check if any of the following apply to you:
Laser Eye Surgery
Epilepsy
Dry Eye syndrome
Conjunctivitis
Psoriasis
Trichotillomania
Alopecia
Cataract
Diabetic Retinopathy
Glaucoma
Herpes Simplex
Currently pregnant
Any other known medical conditions which may affect the suitability for an eyelash treatment?

I understand that there has been no patch test carried out 24hrs prior to treatment. I consent to the treatment being performed. I also understand the risks associated with having artificial eyelashes applied to and/or removed from my existing eyelashes and also understand the importance of following the aftercare and maintenance guide (given after treatment) which will determine how long the lashes last and reduce the chance of any risks.

(*Please note that your treatment may take up to 2hrs so please head to the bathroom if you need to now!)



If yes please state:
Fifth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Fifth Client's Information
Job role:
How did you FIRST hear about Bella Lash Brow?*
Have you had lash extensions before?*
No
Yes
If yes, where have you had them applied (most recent place if more than one)?
Within the last 3 months, have you had any of the following types of lashes? *
individual
strip
cluster
Other
None of the above
If Other, please list:
Are you having your lashes done for:*
If special occasion, please list:
Do you normally wear contact lenses?*
No
Yes
Do you normally wear glasses?*
No
Yes
Do you have or are you being treated for any eye illness or injury?*
No
Yes
Please check if any of the following apply to you:
Laser Eye Surgery
Epilepsy
Dry Eye syndrome
Conjunctivitis
Psoriasis
Trichotillomania
Alopecia
Cataract
Diabetic Retinopathy
Glaucoma
Herpes Simplex
Currently pregnant
Any other known medical conditions which may affect the suitability for an eyelash treatment?

I understand that there has been no patch test carried out 24hrs prior to treatment. I consent to the treatment being performed. I also understand the risks associated with having artificial eyelashes applied to and/or removed from my existing eyelashes and also understand the importance of following the aftercare and maintenance guide (given after treatment) which will determine how long the lashes last and reduce the chance of any risks.

(*Please note that your treatment may take up to 2hrs so please head to the bathroom if you need to now!)



If yes please state:
Sixth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Sixth Client's Information
Job role:
How did you FIRST hear about Bella Lash Brow?*
Have you had lash extensions before?*
No
Yes
If yes, where have you had them applied (most recent place if more than one)?
Within the last 3 months, have you had any of the following types of lashes? *
individual
strip
cluster
Other
None of the above
If Other, please list:
Are you having your lashes done for:*
If special occasion, please list:
Do you normally wear contact lenses?*
No
Yes
Do you normally wear glasses?*
No
Yes
Do you have or are you being treated for any eye illness or injury?*
No
Yes
Please check if any of the following apply to you:
Laser Eye Surgery
Epilepsy
Dry Eye syndrome
Conjunctivitis
Psoriasis
Trichotillomania
Alopecia
Cataract
Diabetic Retinopathy
Glaucoma
Herpes Simplex
Currently pregnant
Any other known medical conditions which may affect the suitability for an eyelash treatment?

I understand that there has been no patch test carried out 24hrs prior to treatment. I consent to the treatment being performed. I also understand the risks associated with having artificial eyelashes applied to and/or removed from my existing eyelashes and also understand the importance of following the aftercare and maintenance guide (given after treatment) which will determine how long the lashes last and reduce the chance of any risks.

(*Please note that your treatment may take up to 2hrs so please head to the bathroom if you need to now!)



If yes please state:
Seventh Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Seventh Client's Information
Job role:
How did you FIRST hear about Bella Lash Brow?*
Have you had lash extensions before?*
No
Yes
If yes, where have you had them applied (most recent place if more than one)?
Within the last 3 months, have you had any of the following types of lashes? *
individual
strip
cluster
Other
None of the above
If Other, please list:
Are you having your lashes done for:*
If special occasion, please list:
Do you normally wear contact lenses?*
No
Yes
Do you normally wear glasses?*
No
Yes
Do you have or are you being treated for any eye illness or injury?*
No
Yes
Please check if any of the following apply to you:
Laser Eye Surgery
Epilepsy
Dry Eye syndrome
Conjunctivitis
Psoriasis
Trichotillomania
Alopecia
Cataract
Diabetic Retinopathy
Glaucoma
Herpes Simplex
Currently pregnant
Any other known medical conditions which may affect the suitability for an eyelash treatment?

I understand that there has been no patch test carried out 24hrs prior to treatment. I consent to the treatment being performed. I also understand the risks associated with having artificial eyelashes applied to and/or removed from my existing eyelashes and also understand the importance of following the aftercare and maintenance guide (given after treatment) which will determine how long the lashes last and reduce the chance of any risks.

(*Please note that your treatment may take up to 2hrs so please head to the bathroom if you need to now!)



If yes please state:
Eighth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Eighth Client's Information
Job role:
How did you FIRST hear about Bella Lash Brow?*
Have you had lash extensions before?*
No
Yes
If yes, where have you had them applied (most recent place if more than one)?
Within the last 3 months, have you had any of the following types of lashes? *
individual
strip
cluster
Other
None of the above
If Other, please list:
Are you having your lashes done for:*
If special occasion, please list:
Do you normally wear contact lenses?*
No
Yes
Do you normally wear glasses?*
No
Yes
Do you have or are you being treated for any eye illness or injury?*
No
Yes
Please check if any of the following apply to you:
Laser Eye Surgery
Epilepsy
Dry Eye syndrome
Conjunctivitis
Psoriasis
Trichotillomania
Alopecia
Cataract
Diabetic Retinopathy
Glaucoma
Herpes Simplex
Currently pregnant
Any other known medical conditions which may affect the suitability for an eyelash treatment?

I understand that there has been no patch test carried out 24hrs prior to treatment. I consent to the treatment being performed. I also understand the risks associated with having artificial eyelashes applied to and/or removed from my existing eyelashes and also understand the importance of following the aftercare and maintenance guide (given after treatment) which will determine how long the lashes last and reduce the chance of any risks.

(*Please note that your treatment may take up to 2hrs so please head to the bathroom if you need to now!)



If yes please state:
Ninth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Ninth Client's Information
Job role:
How did you FIRST hear about Bella Lash Brow?*
Have you had lash extensions before?*
No
Yes
If yes, where have you had them applied (most recent place if more than one)?
Within the last 3 months, have you had any of the following types of lashes? *
individual
strip
cluster
Other
None of the above
If Other, please list:
Are you having your lashes done for:*
If special occasion, please list:
Do you normally wear contact lenses?*
No
Yes
Do you normally wear glasses?*
No
Yes
Do you have or are you being treated for any eye illness or injury?*
No
Yes
Please check if any of the following apply to you:
Laser Eye Surgery
Epilepsy
Dry Eye syndrome
Conjunctivitis
Psoriasis
Trichotillomania
Alopecia
Cataract
Diabetic Retinopathy
Glaucoma
Herpes Simplex
Currently pregnant
Any other known medical conditions which may affect the suitability for an eyelash treatment?

I understand that there has been no patch test carried out 24hrs prior to treatment. I consent to the treatment being performed. I also understand the risks associated with having artificial eyelashes applied to and/or removed from my existing eyelashes and also understand the importance of following the aftercare and maintenance guide (given after treatment) which will determine how long the lashes last and reduce the chance of any risks.

(*Please note that your treatment may take up to 2hrs so please head to the bathroom if you need to now!)



If yes please state:
Tenth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Tenth Client's Information
Job role:
How did you FIRST hear about Bella Lash Brow?*
Have you had lash extensions before?*
No
Yes
If yes, where have you had them applied (most recent place if more than one)?
Within the last 3 months, have you had any of the following types of lashes? *
individual
strip
cluster
Other
None of the above
If Other, please list:
Are you having your lashes done for:*
If special occasion, please list:
Do you normally wear contact lenses?*
No
Yes
Do you normally wear glasses?*
No
Yes
Do you have or are you being treated for any eye illness or injury?*
No
Yes
Please check if any of the following apply to you:
Laser Eye Surgery
Epilepsy
Dry Eye syndrome
Conjunctivitis
Psoriasis
Trichotillomania
Alopecia
Cataract
Diabetic Retinopathy
Glaucoma
Herpes Simplex
Currently pregnant
Any other known medical conditions which may affect the suitability for an eyelash treatment?

I understand that there has been no patch test carried out 24hrs prior to treatment. I consent to the treatment being performed. I also understand the risks associated with having artificial eyelashes applied to and/or removed from my existing eyelashes and also understand the importance of following the aftercare and maintenance guide (given after treatment) which will determine how long the lashes last and reduce the chance of any risks.

(*Please note that your treatment may take up to 2hrs so please head to the bathroom if you need to now!)



If yes please state:
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address
Email*
Check to receive updates and exclusive discounts by e-mail.
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Information
Job role:
How did you FIRST hear about Bella Lash Brow?*
Have you had lash extensions before?*
No
Yes
If yes, where have you had them applied (most recent place if more than one)?
Within the last 3 months, have you had any of the following types of lashes? *
individual
strip
cluster
Other
None of the above
If Other, please list:
Are you having your lashes done for:*
If special occasion, please list:
Do you normally wear contact lenses?*
No
Yes
Do you normally wear glasses?*
No
Yes
Do you have or are you being treated for any eye illness or injury?*
No
Yes
Please check if any of the following apply to you:
Laser Eye Surgery
Epilepsy
Dry Eye syndrome
Conjunctivitis
Psoriasis
Trichotillomania
Alopecia
Cataract
Diabetic Retinopathy
Glaucoma
Herpes Simplex
Currently pregnant
Any other known medical conditions which may affect the suitability for an eyelash treatment?

I understand that there has been no patch test carried out 24hrs prior to treatment. I consent to the treatment being performed. I also understand the risks associated with having artificial eyelashes applied to and/or removed from my existing eyelashes and also understand the importance of following the aftercare and maintenance guide (given after treatment) which will determine how long the lashes last and reduce the chance of any risks.

(*Please note that your treatment may take up to 2hrs so please head to the bathroom if you need to now!)



If yes please state:
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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