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Client Evaluation Form for Lash Extensions

Collect a client's health history and informed consent before applying lash extensions.

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In the Claude connectors directory

Name

Address

Street Address

City

State / Province

ZIP / Postal Code

City/State

Zip

Home/Cell Phone

How did you hear of us?

Health History

Any other health condition not listed

Health Questionnaire

Are you pregnant or nursing? Do you wear contacts? Do you wear glasses? Do you use Retin-A or Accutane? Do you go tanning? Have you had facial treatments? Have you had Botox or injections? Do you use Latisse or lash growth products?

Additional Notes

How fast do you feel your hair grows?

Slow Average Fast

Is there anything else we should know about?

Informed Consent

I understand this may result in stinging and burning, blurry vision should the adhesive enter the eye or should an allergic reaction occur.

I understand and accept

I understand that if the bonding agent comes into contact with my eye, my eye will be flushed with water and I will be given medical attention

Aftercare and Maintenance

I understand that fill appointments are necessary to maintain the original look achieved by replacing the lashes that have fallen out. Most clients require a fill appointment every 2-3 weeks.

I understand and accept

Signature Confirmation

Client Name (Printed)

Client Name (Signature)

Sign here

Lash Extension Specialist:

Date:

Follow-up Appointment Information

Full Fill

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