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Douxluxurylashes@gmail.com
5457 Twin Knolls Rd Columbia, MD

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Home
Services
- Eyelash Extensions
- Yumi Lash Lift
Gallery
Contact

Please be sure to fill out Registration Form accurately. Form is required before receiving Eyelash Extensions. This is beneficial to you and your Lash Tech. This will help the Lash Tech figure out what is best for your lashes, your eyes, and health!

Registration

Instructions *All fields are required before submitting information.
How were you referred? *
First Name *
Last Name *
Birthdate **Year is NOT required. Birthdate is used for specials and gifts on Birthdays!
Phone *
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Email *
Have you ever recieved Eyelash Extensions in the past? *
yesno
Do you wear contacts? *
If so, please remove before the procedure.yesno
Do you rub or pull your lashes? *
yesno
Do you wear glasses? *
Your eyes will be closed during the procedure so you won't need them.yesno
Have you ever had eyelash extensions removed before? *
yesno
Have you ever had a bad experience with Eyelash Extensions? *
yesno
Which side do you sleep on? Please note, that you may experience more eyelash extension loss on the side on which you sleep. *
rightleftback
Do you sleep on your face? *
yesno
History of surgury that affected you hair/natural eyelash growth or loss,history, of disease or other conditions including your eyes *
yesno
Recent eye surgery, wound, or infection? *
yesno
If answered "yes" to any of the 2 previous questions, please explain!
Are you pregnant? *
yesno

Health History

Any known Allergies *If none apply please type "None"

Please note that medications used to treat the following conditions may cause hair/natural eyelash loss. If you are on medications to treat any of the following, please mark them below. If none of the following apply to your situation click "None".

Checkbox *
AcneAllergiesAnticagulantsAutoimmune diseaseBirth Controlconvulsions/epilepsydepressiondiet/weight lossdry eye syndromefungusglaucomagouthigh blood pressurehigh cholesterolHormone imbalance, hormone therapyParkinson's diseaseThyroid diseaseUlcersCancerNone

*Although these are not medical conditions, birth control, and hormone therapy may result in the thinning or loss of natural.

Please mark all that apply. If none of the following apply to your situation click "None". *
AlopeciaAsthmaAutoimmune diseaseBack PainBell's PalsyBlepharitusBrochitits (chronic)ClaustrophobiaCold soreConjunctivitus (pink eye)DiabetesDiabetic retinopathydry eye syndromeEye sties or soresHormonal disorders or changesLeamy eye or excessive tearingMigrainesOcular rosaceaOveractive bladderseizure disordersensitive eyessensitivity to lightsinus problemsstressstroketendency of redness, rashes, or hivesthyroid diseasetrichotillomania (hair or eyelash pulling)None
Other

Do you have an allergy to any of the following? If yes, please provide additional information below.

Acrylates or cyanoacrylates *
yesno
nail adhesives *
yesno
Tape (Bandages) *
yesno
long-lasting or waterproof cosmetics *
yesno
Cosmetic, skin care products, topical creams or other topical products or ingredients *
yesno
Please list any known Allergies. If None apply type "None" *
Allergies
Please list allergies in the box below.
How would you describe your hair growth cycle as compared to others *
fastslownot sure

Consent

Please read and sign I understand the information above is confidential. I have to the best of my knowledge, given an accurate account of my medical history, including all known allergies.
First Name *
Last Name *
Date *

Verification

Please enter any two digits *Example: 12
This box is for spam protection - please leave it blank:

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