Surveypoint

Q1

E-mail

Q2

Medical Details*

Allergy to Latex, plasters, collagen, fish, acrylic nails

Asthma

Hayfever

Claustrophobia

Light Sensitive

Smoker

Eye Disorders

Contact Lens wearer (must be removed for treatment)

Taking HRT or steroids, thyroid medication

Pregnant

Oily skin & hair

Chemotherapy within the last 6 months

Have you worn lash extensions before?

None of the above are relevant to me

Q3

Additional Medical Notes

Q4

The information that I have provided above is correct and true to the best of my knowledge, I give permission to my therapist to perform the patch test and understand that they will take every precaution to minimise or eliminate any negative reactions that may occur as a result of the treatment.*

Q5

I give permission to my therapist to perform the eyelash extensions patch test on me. The therapist has explained to me the procedure and the products that I will be tested with during the patch test.*

Q6

I understand that if my patch test shows a reaction, then I will inform my therapist immediately and I must not go ahead with the treatment. If my patch test result is clear, then I am safe to go ahead with my treatment.*

Q7

I understand that despite a patch test showing a clear result, I could still react to a full set of lash extensions. On the rare occasion of this happening, I will not hold my therapist responsible and I will inform them ASAP. My therapist will assist me in this case and will offer a free removal (if safe to do so) and only after careful assessment of the extensions and eye area.*

Q8

Communication Preferences*

Text

Email

None

Q9

Photographs*

Yes

No

Q10

Date*

Month

Q11

Date*

Day

Q12

Date*

Year

Lash Client Part -Form Fill

E-mail

Medical Details*

Additional Medical Notes

The information that I have provided above is correct and true to the best of my knowledge, I give permission to my therapist to perform the patch test and understand that they will take every precaution to minimise or eliminate any negative reactions that may occur as a result of the treatment.*

I give permission to my therapist to perform the eyelash extensions patch test on me. The therapist has explained to me the procedure and the products that I will be tested with during the patch test.*

I understand that if my patch test shows a reaction, then I will inform my therapist immediately and I must not go ahead with the treatment. If my patch test result is clear, then I am safe to go ahead with my treatment.*

Communication Preferences*

Photographs*

Date*

Date*

Date*