Name *

First Name

Last Name

Contact Number *

(###)

###

####

How did you hear of us? *

Word of mouth

Facebook

Instagram

A local noticeboard

Other

Please tick if any of these apply to you

major eye surgery in the last 6 months

blepharitis

medication that cause temportwnary hair loss

wears contact lenses

Have had recent eye surgery

Dry eyes

Recent illness or operations

Pregnant or breastfeeding

Any medical conditions that may cause hair or eyelash loss

Trichtillomania (hair pulling disorder

Chemotherapy (last 6 months)

Hormonal imbalance

Have you had a lash lift and tint in the last 2 months? *

Yes

No

Please tick below if you wear any of these products on a daily or weekly basis

Top Eyeliner

Foundation

Bottom Mascara or Eyeliner

Eyeshadow

Do your participate in any of these actives on a daily or weekly basis

Sauna

Swimming

Exercise

Do you suffer from hayfever?

Yes

No

sometimes

Do you suffer from watery eyes?

Yes

No

sometimes

Which way to you sleep? *

Right Side

Left side

on my face

on my back

I understand that lash extensions are articifal and do have the ability to melt in a circumstance that they are exposed to a spike in high heat such as Blow Drying a fringe, lighting a cigarette, lighting a candle close to the face, opening a hot oven door . These should all be considered when having lash extensions on *

Yes I understand

No I do not understand and wish to be contacted about this

I understand that I have to lay down for a period of 45min Minimum for a lash refill and Minimum 1.5 hours for a full set of lashes *

Yes I understand

No I do not understand and wish to be contacted about this

I here by agree to have eyelash extensions applied to my natural lashes and consent to the placement and/or removal of the eyelash extensions by the certified professional *

Yes I understand

No I do not understand and wish to be contacted about this

I understand and agree to follow the after-care instructions and for any unexpected circumstance that happen due to not following these instructions are in my own risk and Wink Lashes and Beauty are not entitled to fix any service due to lack of aftercare followed by client *

Yes

I understand that in rare occasions there are risks associated with having artificial eyelashes. I further understand that in rare circumstances eye or skin irritation and discomfort may occur. *

Yes I understand

No I do not understand and wish to be contacted about this

I understand that because of the natural lash cycle and wear and tear, I will need to maintain my extensions with touch up appointments usually recommended about every 2 to 3 weeks to keep them full. *

Yes I understand

No I do not understand and wish to be contacted about this

I understand that I have to inform Wink Lashes and Beauty of any reactions following the appointment up to 14 days after *

Yes I understand

No I do not understand and wish to be contacted about this

I understand that to maintain full lashes I have to book in a maintenance refill at a time frame recommend by my therapist either 2, 3 or 4 weeks after each treatment. If I do not book a refill in the recommended time frame and less than 40% of the lashes are left when you book in than an extra cost will be added for the time needed to fill those extra lashes *

Yes I understand

No I do not understand and wish to be contacted about this

I understand that I am not entitled to a refund if I have a change of service or style, Wink Lashes and Beauty will do their best to accommodate to alter anything following your appointment if they are able too *

Yes I understand

No I do not understand and wish to be contacted about this

I understand that I will have to have to purchase a lash cleanser and brush at an additional $15 ontop of my cost lash service fee *

A lash cleanser and brush will last 4 months and needs to be used every 2nd day to ensure the healthy regrowth of natural lashes and will prevent them to fall out

Yes I understand

No I do not understand and wish to be contacted about this

I understand that I need to communicate 48 hours prior to my appointment if I have lashes currently one that are not done by Wink Lashes and Beauty *

Yes I understand

No I do not understand and wish to be contacted about this

I understand if I ruin, damage or cause my lash extensions to all fall out resulting in not having 40% of lashes left meant of a refill I have to let staff know 48 hour prior to the appointment *

Yes I understand

No I do not understand and with to be contacted about this

I do understand that Wink Lashes and Beauty they strongly believe in providing a professional service that sticks to their beliefs and values that they will apply lash extensions that will not cause any damage to clients natural lashes and if any therapist feels as though they can not uphold that then they have the right with a explanation to the client to decline application of the lash extensions that is in the best interest in the client *

Yes I understand

No I do not understand and wish to be contacted about this

I understand I am completely welcome to bring headphones into my appointment to list to a device during the treatment

Yes I understand