First Name

Last Name

Best Contact Number

E Mail Address

Type of eyealshes interested in?

Individual Eyelashes
Flare Eyelashes
Strip Eyelashes

Are your lashes

None
Thin
Average
Thick

How would you like your lashes to look?

Natural
Thicker
Dramatic

Please check all that apply

Contact Lens Wearer
Eye Illness
Eye Injury
Can you keep your eyes closed and lie still for two hours?
do you have ringworm?
you suffer from allergies?
have you recently had a high fever or severe illness?
do you have an iron deficiency?
to you suffer from alopecia?
do you have a thyroid disease?
do you have eating disorders?
do you tint or perm your lashes?
are you allergic to synthetics?
Permanent eye makeup within the last month?
have you had exposure to swimming pool chemincals?
have you had major surgery or childbirth within the last 120 days?
do you have a hypersensitivity to cyanoacrylate or formaldehyde?
Are you allergic to adhesives?
Do you take medications that lis hair loss as a side effect?
do you have hormonal imbalance or extreme stress?
do you have asthma?
None of the above

Please explain any yes answers to the question above.

Is there any other pertinenet information we should know before proceeding with service?

I have read, understood & agreed to the Hair By Denise Policy & eyelash extension caresheet ?

Yes
No

Electronic Signature ( Please type your name ) for online consult.
Sign your name in ink for your personal estimate.