Name *

First

Last

Date of Birth *

If you under 18years old, we will need parent/guardian consent for the eyelash application.

Address *

Phone Number *

Email *

How did you hear about us? *

Do you wear glasses? *

Yes
No

Do you have frequent eye irritation, itching, or watery eyes? *

Yes
No

Have you previously had lash extensions? *

Yes
No

If yes, any reactions or discomfort during or after the procedure?

Yes
No

If yes, please elaborate on your reactions / discomfort from the procedure

Have you had any recent eye infection / eye surgery? *

Yes
No

If yes, please elaborate on your recent eye infection / surgery

Do you suffer from any of the following conditions? Please select if relevant: *

If you are taking any eye medications (Inc non-prescription), please list in below:

Would you like a patch test? *

Yes
No

If yes to patch test, we suggest returning in 24hours for eyelash extensions after the patch test

Note:
Throughout eyelash extensions, it is important that you do not open your eyes or sudden jolt. If you need to wiggle, feel uncomfortable or open your eyes, please tell lash technician first. This way we can ensure that it is safe for you to do so.
I understand that the eyelash extensions procedure involves glueing synthetic eyelash to natural eyelash and the lash technician holds no liability for my acceptance of this procedure.
I understand the aftercare instruction and to keep my eyes closed throughout the process.
I give consent for photographs to be taken of my lashes and used for the salon portfolio and marketing activities.
I hereby release my eyelash technician and the salon from all claims, demands, damages, actions and cause of action arising out of the performance of the service or any reactions that may occur during and after the treatment that I have elected to.
I completely understand and comply with the above stated.

Have you read and do you affirm that all answers provided above are correct? *

Yes
No

Have you been in contact with a person with a confirmed case of COVID-19? *

Yes
No

It is required by some Government regulations, that you fill out this form and send it PRIOR to your appointment.
When you come to your appointment, please wear a mask that covers from the bridge of your nose to below your chin.
You will be required to wash your hands upon arrival.
Please do not bring anyone else, including children, to your appointment. Only 1 person per appointment.
If you tend to get chilly during your lash appointment, please bring your own blanket.
If you feel unwell or sick or currently awaiting for COVID-19 test result, please reschedule your appointment.

Are you currently waiting for the COVID-19 test result? *

Yes
No

It is required by some Government regulations, that you fill out this form and send it PRIOR to your appointment.
When you come to your appointment, please wear a mask that covers from the bridge of your nose to below your chin.
You will be required to wash your hands upon arrival.
Please do not bring anyone else, including children, to your appointment. Only 1 person per appointment.
If you tend to get chilly during your lash appointment, please bring your own blanket.
If you feel unwell or sick or currently awaiting for COVID-19 Test result, please reschedule your appointment.

Have you had any of the following symptoms in the past 14 days? *

Have you been in contact with anyone with any of the following symptoms? *

Have you travelled overseas in the last 14 days? *

Yes
No

Per the Commonwealth Government instructions, you must self-isolate for 14 days after returning from overseas

Have you been in contact with any persons who have travelled from overseas in the past 14 days? *

Yes
No

Do you affirm that all answers provided in this form are correct? *

Yes
No

When completing this Pre-Entry Consultation Form, you have acknowledged your responsibilities in managing your own personal health in relation to COVID-19 and confirm that all of the above information is true and correct.
We comply with existing obligations on privacy and confidentiality as we understand the importance of it. We are committed to ensuring that the information collected is respected and protected, your information will only be kept for our own record use unless it is requested by law that we have to required to disclose relevant information.

Client Information