PERSONAL INFO Name * First Name Last Name Date of Birth * MM DD YYYY Phone * (###) ### #### Email * How did you hear about Lei Theory? Internet Search Social Media Referral - Let me know who to thank :) REMOVAL Do you currently have lash extensions on? * Yes No Are you receiving a lash removal? * Yes No If yes to either, please list the date of application MM DD YYYY If you currently have lashes on are you experiencing any of the following? check all that apply Discomfort Itching Burning or Stinging Pulling or Pinching Swelling Redness Premature Lash Loss Additional comments or concerns Removal of lashes extensions applied at a foreign studio may expose visible breakage, gaps, thinning, and accumulation damage as a direct result of the original application technique. Lei Theory is not responsible for the condition of my lashes post removal. * I Understand and Acknowledge HISTORY Is this your first time receiving lash extensions? Yes No Please provide a description of your last procedure. List any helpful details that will allow me to customize your experience. Ex: preferences, expectations, etc. Which procedure(s) are you receiving? * check all that apply Lash Extensions Facial Waxing Consultation Please check any contraindications that apply: * check all that apply Eye Infection Corneal Abrasion Anxiety/ Panic Attacks Cyanoacrylate Allergy Glaucoma Thyroid Condition Cancer Claustrophobia OCD Trichotillomania Back or Neck Pain Asthma Dry Eye Excessive Tearing Light Sensitivity Latex Allergy Skin Allergy Skin Disorders Blepharitis Hyper Sensitives Recent Cosmetic/ Facial Procedures Pregnant Breastfeeding Overactive Bladder Seizures Seasonal Allergies NONE apply Please list any medications you are taking: Other relevant health related information: LIFESTYLE Please select any that apply to your lifestyle: check all that apply Hot Yoga Frequent Swimming Active Lifestyle Sauna Facials/ Esthetic Treatments What side do you primarily sleep on? Left Side Right Side Back On Face Skincare and makeup used: * check all that apply Skin Exfoliants Sunscreen Moisturizer Oil Facial Cleanser Skin Serum Makeup Remover Eye Cream Gel Eyeliner Pencil Eyeliner Eyeshadow Primer Eyeshadow Mascara Face Powders Makeup Setting Spray NONE apply How often do you wear strip lashes? * Never Occasionally Frequently (2x a week) Very frequently (3-5x a week) Daily Have you used lash growth serum in the last 6 months? * Option 1 Option 2 Do you have a tendency to pick or pull your lashes? * Yes No Consent I consent Lei theory to provide the following procedure(s) chosen in this consent form * I Consent I Do Not Consent I have read the policies provided for the procedure(s) I'm receiving * I acknowledge I've read Lei Theory's Policies I release the rights to any photos taken before, during or after procedure to be used for educational or marketing purposes. * I Consent I Do Not Consent I understand that on rare occaasions there are risks associated with having lash extensions applied or removed from my natural lashes. I further understand that rare cases as part of the procedure irritation and discomfort can occur. Please initial below I understand and agree to the after-care instructions provided by Lei Theory. I realize and accept failure to adhere to these instructions may cause unsatisfactory results. * Please initial below Thank you! Consent Form
