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Beauty - Consultation
This form is for in salon consultations. Please use the contact form on the homepage for general enquiries.
First Name
Last Name
Email
Phone
Address
Postcode
DOB
How did you hear about us?
Please choose an option
Instagram
Word of mouth
Website
Other
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Do you give permission for your photos to be used on social media?
Please choose an option
Yes
No
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Instagram name
Please enter your General Practitioner's (GP) information below.
GP Name
GP Address
GP Phone Number
Do you have/had any of the following (select all that apply)
Skin condition around the eye area
Lack of sensitivity around the eye area
Epiliepsy
Eczema
Dermititis
Eye infection/inflamation
Styes
Blepharities
Cysts in eye area
Dry Eye Syndrome
Eyelid surgery
Cataract
Glaucoma
Hayfever
Diabetic Retinopathy
Received a patch test
Yes
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Your Signature
Clear
Have you had eyelash extensions before?
Yes
No
If yes, did they meet your expectations?
Yes
No
N/A
Do you wear contact lenses?
Yes
No
Are you currently receiving treatment from a medical professional?
Yes
No
Are you currently taking prescribed medication?
Yes
No
Do you have any allergies/sensitivities to products?
Yes
No
Have you ever had an allergic reaction to adhesive or tape?
Yes
No
DECLARATION : I confirm that the information is correct, to the best of my knowledge. I understand that the Therapist is relying on this information to provide a safe and effective treatment. I take full responsibility for any information I have not given correctly and will undergo a patch test at least 48 hours prior to the treatment. I understand that infill treatments will be required to maintain the appearance of my lashes and that additional charges may apply. I have received aftercare advice. All deposits are non refundable and in the case that appointment should be cancelled or rescheduled, the deposit will be added to your account as credit as long as any changes or cancellations have been made outside of a 48 hour window leading up to your appointment. If this should happen within that 48 hour window, then the deposit will be lost. Signing this means you adhere to these rules.
Read and understood.
Submit
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