Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### Will you be attending? * Yes No Still Unsure Date of Birth * MM DD YYYY How Did You Hear About Us? * LALM Website Google Friend Other What Treatment(s) Are You Receiving Today? * Eyelash Extensions Lash Lift Tint Wax Lash Removal Will This Be Your First Experience With Eyelash Extensions? * Yes No * If No, where have you had lashes applied? * Did you like something specific about your prior set? Do You Wear Contacts? Yes No If yes, please be advised, your appointment will last anywhere between thirty (30) minutes to three (3) plus hours. If you cannot keep your eyes closed with your contacts in comfortably, you will need to remove the,. * Are you currently using a lash serum? * Yes No Please check off any of the following that may apply to you: * Lasik eye surgery Permanent eye makeup Blephroplasty (eye lift) Allergies to adhesives or synthetics Child birth within 120 days Alopecia Thyroid disease Allergic to glycerin Hypersensitivity to cyanoacrylate or formaldehyde Iron deficiency Hormonal imbalance or extreme stress Exposure to chemicals found in swimming pools, bleach, hair dye and hair perm Eating disorder Drugs that can cause temporary hair loss Chemotherapeutic agents used in cancer treatements Retinoids used to treat acne and skin problems Anticoagulants Beta-Adrenergic blockers used to control blood pressure Oral contraceptives Major surgeries within the last 120 days General Information: * Thank you!
