Client Information Name & Surname Appointment Date Physical Address Email Phone Who Referred you? Please Check The Relevant Boxes: Please Check The Relevant Boxes: Recent eye surgery Pregnant or breastfeeding Recent eye irritation or injury Dry eyes Seasonal allergies Eye infection Permanent eyeliner Previous allergic reactions to eyelash extension adhesive Very oily hair/skin Allergies to adhesives found in band-aids or medical tape Allergies to cyanoacrylate adhesives(i.c. surgical glue) Allergic to latex or acylic Recent illness or operations? Any medical conditions that may cause hair and eyelash loss: hyperthyroidism, alopecia areata Trichotillomania ( hair pulling disorder) Chemotherapy treatments in the last 6 months Contact Lenses Frequent eye irritation, itching or watering eyes Blepharoplasty Blepharitis (inflammation of cyclids) Hormonal imbalance Other Medical Information Submit