On The Glow

Lash Lift & Tint History

Have you ever had a Lash Perm (Lash Lift)?

Yes

Please choose an option.

If YES, when did you have your last lash perm/lift?

Please answer this question.

If YES, was it a good experience?

Yes

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If NO, please describe:

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Did you experience any reaction to the tint?

Yes

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If YES, please describe:

Please answer this question.

Which best describes the look you would like to achieve for your lashes?

Fully Lifted

In Between

Soft Natural Curl

Please select at least one option.

Have you had a lash/brow tint before?

Yes

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Please complete all required fields in this section.

Beauty Regime & Eye Health

Please check any of the following that may apply to you (Eyes Related):

Eye surgery

Eye illness or injury

Dry eyes

Seasonal allergies

Eye infection

Permanent eye make-up

Blepharoplasty

Blepharitis (inﬂammation of eyelids)

Please select at least one option.

Please check any of the following that may apply to you (Generally Relating to Eyelashes):

Allergies to adhesives found in band-aids or medical tape

Allergies to preservatives in saline solutions

Sensitivity or claustrophobia when your eyes are closed for long periods

Retinoids used to treat acne and skin problems (such as accutane or retin a)

Hormone imbalance

Recent severe illness or injury

Pregnancy or recent childbirth

New prescriptions or recently prescribed oral contraceptives

Types of medical conditions that may contribute to hair and eyelash loss: hyperthyroidism or hypothyroidism, alopecia areata, lupus, diabetes

Vitamin and mineral deficiencies that may contribute to hair and eyelash loss: A, F, B, Selenium, Zinc, Iron

Trichotillomania (hair pulling disorder)

Medications that may contribute to hair or eyelash loss: chemotherapeutic agents used in cancer treatment, Anticoagulants (blood thinners), beta blockers (used to control blood pressure)

Please select at least one option.

Other Medical Information:

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Please check all of the below products you use:

Lash Growth Serum

Eyelash Curler

Waterproof Mascara / Regular Mascara

Eyeliner

Oil-Based Products (creams, removers, etc)

Contact Lenses

Please select at least one option.

Please describe any helpful information about your lashes.

Please answer this question.

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Photo/Video Consent

I grant permission to the rights of my image, likeness and sound of my voice as recorded in audio or video tape without payment or any other consideration.

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I affirm my procedure is elective and in no way medically necessary. I chose to be here on my own free will.

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Final step

Your contact details

We’ll use this to attach your responses.

First name

First name is required.

Last name

Last name is required.

Phone

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Lash Lift and Tint Form

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