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EYELASH EXTENSION

INTAKE & CONSENT FORM

Today's Date: August 26, 2019

First Client's Name

First Name*

Last Name*

Phone*
First Client's 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 60 days, have you had any of the following types of lashes?
individual
strip
flare
other

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?

If yes please state:

I understand that there is no patch test being carried out 24hrs prior to treatment. 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!)

First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's 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 60 days, have you had any of the following types of lashes?
individual
strip
flare
other

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?

If yes please state:

I understand that there is no patch test being carried out 24hrs prior to treatment. 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!)

Third Client's Name

First Name*

Last Name*
Third Client's 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 60 days, have you had any of the following types of lashes?
individual
strip
flare
other

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?

If yes please state:

I understand that there is no patch test being carried out 24hrs prior to treatment. 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!)

Fourth Client's Name

First Name*

Last Name*
Fourth Client's 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 60 days, have you had any of the following types of lashes?
individual
strip
flare
other

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?

If yes please state:

I understand that there is no patch test being carried out 24hrs prior to treatment. 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!)

Fifth Client's Name

First Name*

Last Name*
Fifth Client's 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 60 days, have you had any of the following types of lashes?
individual
strip
flare
other

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?

If yes please state:

I understand that there is no patch test being carried out 24hrs prior to treatment. 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!)

Sixth Client's Name

First Name*

Last Name*
Sixth Client's 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 60 days, have you had any of the following types of lashes?
individual
strip
flare
other

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?

If yes please state:

I understand that there is no patch test being carried out 24hrs prior to treatment. 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!)

Seventh Client's Name

First Name*

Last Name*
Seventh Client's 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 60 days, have you had any of the following types of lashes?
individual
strip
flare
other

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?

If yes please state:

I understand that there is no patch test being carried out 24hrs prior to treatment. 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!)

Eighth Client's Name

First Name*

Last Name*
Eighth Client's 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 60 days, have you had any of the following types of lashes?
individual
strip
flare
other

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?

If yes please state:

I understand that there is no patch test being carried out 24hrs prior to treatment. 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!)

Ninth Client's Name

First Name*

Last Name*
Ninth Client's 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 60 days, have you had any of the following types of lashes?
individual
strip
flare
other

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?

If yes please state:

I understand that there is no patch test being carried out 24hrs prior to treatment. 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!)

Tenth Client's Name

First Name*

Last Name*
Tenth Client's 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 60 days, have you had any of the following types of lashes?
individual
strip
flare
other

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?

If yes please state:

I understand that there is no patch test being carried out 24hrs prior to treatment. 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!)

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*
A signed copy of this waiver will be sent to the email address you provide.
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.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's 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 60 days, have you had any of the following types of lashes?
individual
strip
flare
other

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?

If yes please state:

I understand that there is no patch test being carried out 24hrs prior to treatment. 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!)

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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