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Bella Via Medical Spa
2865 N Reynolds Rd #240
Toledo, OH 43615
Phone: (419) 534-6552
Monday, Wednesday, Friday: 8:30 a.m.–6 p.m.
Tuesday, Thursday: 8:30 a.m.–7 p.m.
Every other Saturday: 9 a.m.–4 p.m.

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Eyelash Extensions Intake Form

Eyelash Extensions Intake Form

Name: Bella Via Medical Spa
Address: 2865 N Reynolds Rd #240, Toledo, OH, 43615
Telephone: (419) 534-6552

"*" indicates required fields

Step 1 of 3

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First Name*

First

Last Name*

Last

Date of Birth*

Age*

Gender*

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Work Phone

Email*

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?*

If Friend/Other, who referred you?*

Area Specifics

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:*

Please specify*

Do you do any of the following to your eyelashes?

Please check all that apply.

Curl

Perm/Lift

Tint

Are you having eyelash extensions applied for:*

Daily Wear

Special Occassion

Do you wear contacts?*

Do you habitually rub, pull, or pick your eyelashes for any reason?*

Do you have, or are you being treated for, any eye illness or injury?*

What side do you predominately sleep on?*

Do you participate in physical/ sport activities, such as exercising? If yes, which types and how often?*

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)*

if none, write 'no'.

Are you able to keep your eyes closed and lie still for up 2 hours or longer?*

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

Consent

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 authorize Bella Via and my esthetician and lash professional to perform an eyelash extension procedure on me. I understand this procedure requires individual synthetic eyelashes to be adhered to my own natural lashes. I understand that it is my responsibility to remain still during the application and to keep my eyes closed during the entire process until otherwise advised.*

Consent 6*

I have been fully informed as to the methods and procedures concerning eyelash extension application. The known risks of the cosmetic procedure I have chosen have been disclosed to me. Some cases may result in complications such as: transient eye redness and irritation, and allergic reaction to the adhesive, under eye gel patches, or any other products used. If at any time I am uncomfortable with the eyelash extension procedure, I will inform the esthetician and she will gladly rectify the problem, including ending the session if I or the esthetician wish. If the esthetician is uncomfortable with applying lashes to me, she will discuss her concerns with me and may end the session if necessary*

Consent 7*

It has been represented to me that no guarantees, warranties, promises, commitments or other statements as to the results of this service have been made. I acknowledge that I have received no particular representations or guarantees, and I am consenting to the procedure at my own risk.*

Consent 8*

I have revealed or disclosed on the Eyelash Extension Intake Form all conditions and circumstances regarding my health and health history, medications being taken, and any past reactions to products used or medications taken. Additional conditions may occur or be discovered during or after the procedure, which could affect my ability to tolerate the procedure.*

Consent 9*

I understand the longevity of my eyelash extensions requires my careful maintenance. I have been given and understand the instructions for after-care that have been stated on the Eyelash Extensions Recommendation Form.*

Consent 10*

I have taken out my contacts before the procedure, if applicable.*

Consent 11*

I, as herein signed, release, give up, acquit, and discharge Bella Via and their trained lash professional including any partnership, corporations, or company associated with said individual from any claims or damages of any nature. I further agree that this release shall be in contemplation of any possible damages, either known or unknown at the signing of this Waiver and Release Form, and said damages are specifically waived following the signing of this Waiver and Release Form. I agree to hold Bella Via or Reconstructive and Aesthetic Surgeons nameless and harmless from any and all damages.*

Consent 12*

I release my esthetician and lash professional from any responsibility for pre-existing conditions I have not revealed, or any consequential change to those conditions that arises subsequent to the procedure.*

Consent 13*

I understand that I am responsible for any medical treatment I may need to receive as a result of getting this procedure.*

Consent 14*

I accept full responsibility for these and any other complications, which may arise or result during or following the eyelash extension procedure(s), which are to be performed at my request.*

Consent 15*

I, the client herein signed, certify that I have read and had explained to me and fully understand the above Waiver and Release Form. I certify that I have consulted with my esthetician and trained Lash Professional and have read all applicable literature given to me. I have completed the Eyelash Extension Intake Form to the best of my knowledge. I accept the explanation of potential complications and risks described herein. I certify I am of sound mind, and I am fully capable of executing this waiver and release form for myself. I, the undersigned client, acknowledge and fully understand that there might be other unknown risks not reasonably foreseeable at this time.*

I consent to having “Before” and “After” photographs of said procedure(s) for the purpose of documentation in my file.*

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.