Eyelash Extensions Intake Form Personal Information Area Specifics Consent Name Full Name * DOB * Age * Gender * Address City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip * Home Phone Cell Phone * Work Phone Email Address * Your email address will be used for appointment confirmations, quarterly newsletters, and to alert you of specials and promotions. Occupation How were you originally referred to Bella Via? Dr. Colville Dr. Zavell Website Friend Other Is this the first time that you have had eyelash extensions applied? If no, where did you have them applied? * Please indicate if you have worn any of the following types of eyelashes within the last 60 days: * Individual Strip Flare Other Do you do any of the following to your eyelashes? (Please check all that apply.) Curl Perm Tint Are you having eyelash extensions applied for: Daily wear Special Occassion Do you wear contacts? * Yes No Do you habitually rub, pull, or pick your eyelashes for any reason? * Yes No Do you have, or are you being treated for, any eye illness or injury? * Yes No What side do you predominately sleep on? * Left Right Please list any eye drops or eye medications that you are currently using * Write 'n/a' if not applicable. Do you have any allergies to adhesives, tape, paper tape or synthetics? If so, please list your reaction(s) * Are you able to keep your eyes closed and lie still for up 2 hours or longer? * Yes No Please check any of the following that apply to you Lasik Eye Surgery Dry Eye Permanent Cosmetics Blepharoplasty Microdermabrasion Seasonal Allergies Alopecia Thyroid Diseases Glycerin Allergies Iron Deficiency Ringworm Major Surgery Eating Disorders Oral Contraceptives Anticoagulants Retinoids Accutane Beta-adrenergic Blockers Chemotherapeutic Agents Hormonal Imbalance Recent High Fever Severe Illness Flu Symptoms Extreme Stress Drugs that Cause Hair Loss Childbirth within the last 120 days Exposure to Chemicals in Swimming Pools, Bleach, Hair Dye, or Perms Hypersensitivity to Cyanoacrylate or Formaldehyde Please read and check the following: consent_1 To secure all Full Set appointments, I agree that I must pay a deposit of $50.00. A 48-hour notice is required if I need to cancel or reschedule these appointments. In the event that I miss my appointment or cancel/reschedule within 48 hours of my appointment time, Bella Via will keep the $50.00 deposit consent_2 I understand that there are risks associated with the application and/or removal of artificial eyelashes. These risks include, but are not limited to: eye irritation, eye pain, discomfort, and in rare cases, blindness. consent_3 As part of this procedure, I understand that a certain amount of eyelash adhesive will be used to apply each extension to my existing eyelashes. Although the certified lash artist may apply and/or remove the eyelash extensions properly, I understand that there is a possibility that the adhesive may become dislodged during or after the procedure, which may irritate my eyes or require further follow-up care. consent_4 I understand that it is recommended to schedule Lash Fill appointments every 2-4 weeks. If I do not schedule a Lash Fill within 5 weeks, I understand that I will need to schedule another Full Set application at $250. consent_5 I have read and completed the Eyelash Extensions Intake & Consent form in its entirety, and have answered everything to the best of my ability. I have been informed of potentially harmful or negative side effects that may be caused by the application and/or removal of eyelash extensions. I consent to having * These photographs MAY be used anonymously on your website or in your brochure for advertising purposes. These photographs MAY NOT be used anonymously on your website or in your brochure for advertising purposes.