Client Consultation Form

Client Consultation Form

Please provide the information requested below. This information will only be used to determine the suitability of the treatment. All information supplied will remain confidential and stored securely.

First Name

Email Address

Post Code

Last Name

Phone Number

Date of Birth

Do you have any known allergies?

Yes

Do you have Asthma?

Yes

Do you suffer from Hayfever?

Yes

Do you suffer from Claustrphobia?

Yes

Do you have any sensitivity to light?

Yes

Have you had Chemotherapy in the last 6 months?

Yes

Are you pregnant?

Yes

Do you smoke?

Yes

Do you have any eye disorders or have previously had any operations in or around the eye?

Yes

Do you have any physical conditions or complaints that will effect your comfort when laying still for longer than one hour?

Yes

Do you have oily hair and/or skin?

Yes

Do you wear contact lenses? (If yes,these must be removed throughout treatment)

Yes

(Do you perm or tint your lashes? If so please provide the date of your last treatment)

Yes

Contra-indications (unable to perform treatment). Do you have any of the below conditions; Conjunctivitus, Stye's, Blepharitis, Cataract, Glaucoma, Chalazae, Hypersensitivity, Cuts or bruising around the eye, Iritis, Hayfever/watery eyes, Cold/Flu/Coronavirus, Implanted/permanent contact lenses.

Yes

If you answered yes to any of the above questions, please provide any further relevant information.

Covid 19

In light of the current pandemic, we have implemented the necessary safety precautions to ensure the health and safety of our therapists and clients. In order to best ensure your safety and that of your therapist, please ensure that you adhere to the following safety measures;

Use the hand sanitizer provided upon entering the treatment room
Bring your own face mask and wear it throughout the appointment
Attend your appointment alone
Wear as little eye makeup as possible to reduce appointment time
Reschedule your appointment if you have any symptoms of covid 19 or have been in contact with anyone who has Covid 19 in the last 14 days.

Although we have taken every precaution to ensure your safety, attending the appointment is at your own risk and Loft Lashes/Hydranback Ltd accepts no responsibility if you contract covid 19/Coronavirus as a result of your appointment.

I declare that I understand and agree with the above and that I do not currently have any sympoms of Covid 19 (New continuos cough, High Temprature/Fever, Change or loss of sense of taste or smell.

DISCLAIMER

The information that I have provided above is correct and true to the best of my knowledge. I give permission to my therapist to perform the patch test behind my ear on ON THE DAY or 24 HOURS PRIOR TO TREATMENT. I understand that they will take every precaution to minimize the risk of a reaction that may occur during my treatment. (This includes equipment and personal health, hygiene & safety)

I UNDERSTAND THAT IF I HAVE A REACTION TO THE PATCH TEST I WILL INFORM MY THERAPIST IMMEDIATELY AND MUST NOT GO THROUGH WITH THE TREATMENT.

If my patch test is clear then I am safe to go ahead with my treatment.

I understand that despite a patch test showing a clear result, I could still react to a full set of lash extensions. On the rare occasion of this happening, I will not hold my therapist or Loft Lashes (Hydranback Ltd) responsible and I will inform them ASAP. My therapist will assist me in this case and will offer a free removal (if safe to do so) after a careful assessment of the extensions and eye area.

CANCELLATION POLICY

Scheduled appointments canceled last minute (24 hours or less prior) will result in a loss of earnings for your therapist as the appointment scheduled cannot be rebooked in such short space of time. In this case you will be charged the full amount to cover the loss of earnings and time.

PATCH TEST - Your treatment your therapist to perform requires patch test behind the ear. The test must be performed on the day of treatment or 24 hours prior to the treatment. Please indicate which you prefer (patch tests performed 24 hours before treatment will require a time slot to be arranged with your therapist)

On the day

24 Hours prior to treatment

I declare that the info I’ve provided is accurate & complete. I have read, understand and agree with all of the above information and terms and conditions.

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