Sam Eye Glam

Client
Information Form

Eyelash Extensions

1Your details
2Waiver and consent

About you

First name

Last name

Address (optional)

Mobile phone number

Date of birth

Email address

Best method of contact

Phone callTextEmail

How did you hear about us?

WebsiteInstagramFacebookFriend / other

Health and lash history

Certain conditions may affect lash retention and growth, how often a fill appointment is needed, and whether you are a good candidate for eyelash extensions.

Check any conditions that apply to you

Glycerin allergyLatex allergyAllergy or hypersensitivity to formaldehyde, cyanoacrylate or adhesives/gluesUse of oral contraceptivesCurrent pregnancyRecent childbirthHormonal imbalanceRecent eye surgeryRecent major surgeryUse of retinoids (e.g. Accutane or Retin-A)

Use of drugs that cause hair lossChemotherapeutic agentsIron deficiencyPermanent eye makeupDry eyesSensitive eyesWatery eyesAlopeciaAntibioticsClaustrophobiaExtreme stress

Any other conditions not listed? (optional)

Eye medication or drops you currently use (optional)

Are you getting extensions for daily wear or a special occasion?

Daily wearSpecial occasion

Is this your first time applying eyelash extensions?

YesNo

Do you wear glasses or contacts?

GlassesContactsBothNone

What side do you usually sleep on?

Left sideRight sideBackStomach