Name:* First Last Parent / Guardian Name (if underage): First Last Date:* Date Format: MM slash DD slash YYYY Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Birthdate:* Date Format: MM slash DD slash YYYY Emergency Contact Name:* First Last Phone Number:*How did you hear about us?* Instagram Facebook Google Friend / OtherIf other, please provide source:Is this the first time you’re having lash extensions applied?*YesNoIf you have, where and what was your experience like?Are you having lash extensions applied for:* Special Occassion Daily Wear OtherIf other, please provide ocassion:What are your lash goals? (check all that apply)* Longer Fuller Dramatic Mascara-look NaturalDo you wear contact lenses or glasses?*YesNoDo you have, or are you being treated for any eye illness or injury?*YesNoDo you habitually rub, pull, or pick your lashes for any reason?*YesNoAre you able to keep your eyes closed, avoid talking and lie still for up to 2 hours or longer?*YesNoPlease check any activities you participate in:* Hiking Swimming Sauna Room Hot Yoga Gym Jacuzzi Marathons OtherIf other, please explainWhat position do you sleep?* Left Right Stomach BackPlease check off any of the following that might apply to you: Laser Eye Surgery Dry Eye Pink Eye (Conjuctivitis) Seasonal Allergies Allergies to ADhesives or Synthetics Irritated or Broken Skin Recent Chemical Peel Hypersensitivity to Cyanoacrylate or Formaldehyde Hormonal Imbalance or Extreme Stress Chemotherapeutic Agents Used in Cancer Treatment Cataract Surgery Diabetic Retinopathy Medication causing temp. hair loss: Sty Blepharoplasty Eczema on Lids Psoriasis on Lids Accutane Use Permanent Makeup Allergies to Latex Allergies to Acrylic Nails Alopecia Lash Loss Cataract Blephartitis Glaucoma None ListedMedication causing temp. hair loss.I understand that this procedure requires synthetic eyelashes to be adhered on to my own natural eyelashes using the very precise application of placing an extension (classic individual or volume fan) on a single natural eyelash.* I agreeIt’s my responsibility to keep my eyes closed and be still during the entire procedure. Please do not bring company.* I agreeI acknowledge that I’ve been informed of potentially harmful or negative side effects that may be caused by the application or removal of eyelash extensions and hereby fully release, agree to hold harmless and forever discharge Ne’Vishia Osbourne, Esthetician, from all liability, demands, or claims associated with this procedure. Risks of this procedure may result in, but not limited to, eye redness and irritation. Products used during this procedure may release fumes and can cause eyes to water. If any unusual symptoms, injury or allergy is suspected, all appointments will cease until cleared by your physician.* I agreeI agree to disclose all medical history and any changes when returning, including skin conditions and/or any allergies that I may have to latex, surgical tapes, cyanoacrylate, etc.* I agreeIf yes, please list:I understand that having eyelash extensions requires careful maintenance. I agree to follow the aftercare instructions given to me, especially, daily cleansing.* I agreeWhat skincare regimen or products are you currently using?If I need to cancel or reschedule any of my appointments, I will inform you ASAP. If I give less than a 24-hr. notice, I will forfeit my deposit and/or agree to pay a late cancellation fee (50% of service) or if no call/no-show (100% of service).* I agreeArriving late will reduce the time of service. If I am more than 15 minutes late, my appointment will be cancelled with a late fee. This is to ensure there is enough time to complete the service and out of consideration to the clients following after.* I agreeFill prices depend on quantity remaining. Anything less than 30 lashes per eye or after 30 days since last service, will require a full set charge. Refill pricing on work done elsewhere is calculated and based on consultation. Removal and full set may be required.* I agreeI agree to show up to my appointment without any eye makeup. If I show up with makeup, it will need to be removed (cleansing fee $10). Extension application time may be reduced due to time spent on removing makeup.* I agreeI give permission to Ne’Vishia Osbourne, Esthetician at “Xclus3 Winks” to show my before and after photos and/or videos to potential clients as needed without claim (e.g. Facebook, Instagram, website, etc.)* I agreeI consent to having a text message and/or email reminder 24-48 hours before appointment (if so, please make sure cell phone number is provided.) Preferred correspondence:* I agree Phone / Text EmailI understand “Xclus3 Winks” reserves the right to refuse service to anyone at any time for any reason.* I agreeI have been offered a patch test and* Patch test was performed I declin a patch testI confirm that I have read and fully understand all risks and am signing voluntarily, agreeing to proceed with services.* I agree