Client Record Card Please complete all sectionsName *First and SurnameDate of birth mm/dd/yyyyOccupation Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryEmail *Phone *Doctor Surgery Date Signature I hereby authorise the fully trained and certified Nouveau Lashes technician named to perform upon myself a Nouveau Lashes treatment. I understand that it is not the responsibility of the technician to diagnose a client's susceptibility to allergies. I accept full responsibility for determining the treatment outcome (which may include decisions regarding the degree of lash curl, length and colour). This has been agreed during the course of my consultation. I have read and understand the Aftercare leaflet given to me and realise that I am responsible for the general care of my lashes. Extend Lash Extension maintenance requirements: I understand that maintenance procedures are required to keep Extend lashes looking thick, full and conditioned. I am aware that I will be charged an additional fee for any further work. Express Lashes removal requirements: I understand that Express lash extensions may be professionally removed at the salon at which they were applied or removed at home using Nouveau Lashes Extension Remover.I have read the terms and conditions and agree.How did you hear about us? - select -InstagramFacebookGoogleA friendyell.comA flyerOtherNotes Allergies YesNoAlopecia / Hair loss YesNoBlepharitis YesNoCataracts YesNoConjunctivitis YesNoContagious disease YesNoDiabetic retinopathy YesNoDry eye syndrome YesNoEczema YesNoEye infection cyst / stye YesNoGlaucoma YesNoHay fever YesNoHives YesNoHormone imbalances YesNoHypersensitive skin YesNoLice YesNoMenopause YesNoPsoriasis YesNoRecent beauty treatment YesNoRosacea YesNoSensitive eyes YesNoSeizures YesNoSkin or eyelid infection / disorder YesNoTrichotillomania YesNoWeak / brittle lashes YesNoAre you presently undergoing any medical treatment? YesNoAre you pregnant or nursing YesNoDo you wear contact lenses YesNoHave you received lash services before YesNoIf answered yes to any of the consultation questions, please provide details VerificationPlease enter any two digits *Example: 12This box is for spam protection - <strong>please leave it blank</strong>:
