Lashes ClientsIf you would prefer to print this form and fill it out by hand, please click here. Name * First Name Last Name Email * Have you completed the Skin Care Evaluation form? * If not, please complete this mandatory form at amcesthetics.com/forms/ Yes No Have you ever received eyelash extensions? * Yes No If yes, when and how frequently? Any adverse reactions? (Please describe symptoms). Have you had eyelash extensions removed? * Yes No Have you used under eye gel patches before? * Yes No If yes, when and how frequently? Any adverse reactions? (Please describe symptoms). Have you had permanent cosmetics applied to your eye area? * Yes No If yes, when and how frequently? Any adverse reactions? (Please describe symptoms). Do you wear glasses? * Yes No Do you wear daily disposable, extended wear, or permanent contacts? * Yes No Do you have a tendency to rub your eyes or pull on your eyelashes? * Yes No Do you go tanning (in salon or outside) or get spray tans? Yes No If yes, please elaborate. How frequently and which type of tanning? Pregnancy Are you pregnant? * Yes No If yes, which trimester? 1 2 3 If yes, have you discussed having this service with your doctor? Yes No Which side do you sleep on? * Please note that you may experience more eyelash extension loss on the side on which you sleep. Right Left Back Stomach Do you exercise? * Yes No If yes, please elaborate. Type of activities, frequency per week, indoors or outdoors, and anything relevant. Are you on a special diet? * Please be advised that healthy natural eyelashes and hair growth require a diet rich in amino acids and protein. In addition, low-carb, low-protein, and quick-results diets may affect the body's chemical balance, which can lead to loss of or damage to hair/natural eye lashes. Yes No Brands and products Please specify below which brands and products you currently use around your eye, as well as the frequency of use. Facial cleanser: Facial mask: Facial toner: Facial primer: Day moisturizer: Night moisturizer: Facial sunscreen: Eye treatment: Eye primer: Eye cream: Eye serum: Eye makeup remover: Eyeliner: Eye shadow: Mascara: Eyelash fortifier / conditioner: Brow products: Hair, skin, and nail supplements: WAIVER AND RELEASE I acknowledge that I have read the Xtreme Lashes Waiver and Release Form and agree to all statements within. * Click here to view form. Yes Thank you!
