About
Contact & Coaching
Events
Blog
Navigation
About
Contact & Coaching
Events
Blog
New Client Form
Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Phone Number
*
(###)
###
####
Email Address
*
Occupation
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Medical Information
Do you have any allergies?
*
No
Yes
If yes, please explain:
Please list any medications you are currently taking:
Please list any conditions you currently have, or that have affected your health in the past.
*
(heart condition, surgery, varicose veins, cancer, etc.)
Please list any communicable or contagious diseases.
*
Are you currently under medical supervision?
*
No
Yes
If yes, please explain:
Are you pregnant?
*
No
Yes
If yes, please explain:
Do you exercise?
*
No
Yes
If yes, what type of activity and with what frequency?
Emergency Contact
Name of Emergency Contact
*
First Name
Last Name
Relation
*
Phone Number of Emergency Contact
*
(###)
###
####
Service(s)
Service(s) of Interest
*
Massage
Eyelash Extensions
Facials
Sugaring
Massage
Please answer the following questions if you are interested in our Massage service.
Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort?
No
Yes
If yes, please explain:
What repetitive movements do you repeat in your work, sports or hobbies?
Eyelash Extensions
Please answer the following questions if you are interested in our Eyelash Extension service.
Have you ever received Eyelash Extensions before?
No
Yes
Have you ever had Eyelash ExtensionsD removed?
No
Yes
Do you wear glasses?
No
Yes
Do you wear contacts?
No
Yes
Do you have a tendency to rub your eyes or pull on your lashes?
No
Yes
Have you had a history of any diseases, conditions, injuries, or surgeries relating to your eyes that have affected your hair/natural eyelash growth or loss?
No
Yes
Please check the appropriate box(s) if you have an allergy to any of the following:
Acrylates or Cyanoacrylates
Nail Adhesives
Tape (bandages)
Massage
Long-lasting or waterproof cosmetics
Cosmetics, skin care products, topical creams or other topical products or ingredients
Other
If you chose 'other,' please explain:
Thank you for completing the Lily Buckner New Client Form!
We hope to see you soon!