NAME:_________________________________________________
EMAIL ADDRESS:______________________________________________
CELL PHONE NUMBER:_______________________________________________
HOW DID YOU HEAR ABOUT US: ______________________________________________
REFERRAL NAME: ______________________________________________________
Proper home care is crucial for maintenance of your Lash or Brow enhancements. For best results you must follow all recommendations given to you on your take home aftercare sheet.
I grant Luxy Beauty Courses permission to use any photos or images taken for advertising purposes.
Clients who are hyper sensitive or have concerns with allergies MUST have a patch test done at least 24 hours prior to the procedure.
It has been recommended to perform a patch test prior to any Eyelash Extension procedure; however, I do not want a patch test against recommendation of the technician and I am waiving the patch test.
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Please circle all that apply:
Positive Reaction to Patch Allergy Test
Cysts
Cuts, Abrasions or Swelling Near Procedure Site
Recent Lash Service
Recent Operations Near Procedure Site
Skin Traumas
Keratitis
Contact Lenses (Remove prior to service)
Weak Eyelashes (Recommended growth serum, review in 2 months)
Sties
Blepharitis
Chemotherapy or Post Chemotherapy
Eye Infection
Skin Disease
Glaucoma
Alopecia
Habits of Rubbing or Picking Your Lashes
I’ve received a thorough consultation and pledge to follow the maintenance recommendations made by my technician. I take full responsibility for the maintenance of my Lash/Brow enhancements. The technician has discussed the realistic results that I will be able to achieve from this service
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CLIENT SIGNATURE:
TECHNICIAN SIGNATURE:
DATE:
For Viewing Purposes Only