Another Level 3D Client Intake Form

Please complete before your appointment. If you can, please print before hand.

Another Level 3D Luxury Eyelash Extension Client Intake Form

 

Name: _____________________________ DOB:_____________  Age:_____ Gender: ____

Address: _____________________________  City: ______________ State:_____ ZiP: _____

Phone Number: _____________________________________

Email Address: _______________________________________________________ (used for promo, offers, birthday wishes, reminders and never shared)

 

Is this the first time you’ve had lash extensions? __Yes   __ No

In the past 60 days have you worn the following? __Individual lashes  __ Strip lashes __Extensions

Do you wear contacts?  __Yes __No

Do you habitually rub, pull, or pick your eyelashes for any reason? __Yes  __No

Do you have or are you being treated for any eye illness or injury?  __Yes __No

What side do you predominately sleep on?  __Right __Left

Please list any eye drops or eye medications that you are currently using: _______________________________________________________________________________

 

Do you have any allergies to adhesives, tape, paper tape or synthetics? ___Yes  ___No __Not Sure

If so, please list your reaction(s): _______________________________________________________________________________

 

Are you able to keep your eyes closed and lie still for up to 2 hours or longer? __Yes  __No

 

Please check any of the following that apply to you:

__Laskik Eye Surgery  __Dry Eye __Permanent Cosmetics  __Blepharoplasty __Microdermobrasion

__Seasonal Allergies  __Alopecia __Thyroid Disease  __Glycerin Allergies __Iron Deficiency

__Ringworm  __Major Surgery   __Eating Disorder __Pregnant  __Oral Contraceptives __Anticoagulants  __Retinoids __Accutane __Chemotherapy past 6 months  __Hormone imbalance

__Recent High Fever  __Severe Illness __Flu Symptoms  __Extreme Stress __Drugs that cause hair loss   __Extreme Stress __Exposure to Chemicals in swimming pools, bleach, hair dye, or perms  __Use lash growers like Latisse __Sensitivity to cyanoacrylate, latex, or formaldehyde (found in most lash adhesive)