Name* First Last Address* Street Address Address Line 2 City State Post code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email* Date* DD slash MM slash YYYY How did you hear about us?* Have you had this service before?* Have you had any reactions?* Medical History*Please check any that apply to you. None of those listed Sensitive eyes Watery eyes Oily skin Eczema or Dermatitis Eye disease Epilepsy Recent Eye Surgery Currently pregnant or lactating Alopecia (hair loss) Bell’s Palsy (facial Paralysis) Inflammation of the skin Blepharitis Wear contact lens/glasses Trichotillomania (Hair Pulling Disorder) Conjunctivitis Allergies*Please check any that apply to you. None known Latex/band aids Medical tape Hay fever Glue/bonding agent Adhesives Are you taking HRT?* Yes No Have you or are you taking Roaccutane?* Yes No Have you had any treatments for cancer?* Yes No How long ago?* Are you currently receiving treatment from a medical Practitioner?* Yes No Have you got any other allergies/conditions?Not sure if you are allergic? Book in for a free consultation and patch test. This will take half an hour and we will be able to go through the process of applying lash extensions with you. The patch test includes using all our products on your skin (glue, tape cleanser etc), to determine if you are a candidate for eyelash extensions. However it does not 100% guarantee that after a fullset of eyelash extensions you will not react, it is just an indicator to whether or not you are allergic to any of our products before committing to any services. This needs to be scheduled at least 48hrs before your first appointment.I acknowledge that I have read and understood the terms and conditions set by Minht Artistry. I verify that I am over the age of 18 and confirm that all the information I have provided is true and I have answered all questions to the best of my knowledge. I give Minht Artistry permission to complete the beauty treatment.Consent*I acknowledge that I have read and understood the terms and conditions set by Minht Artistry. I verify that I am over the age of 18 and confirm that all the information I have provided is true and I have answered all questions to the best of my knowledge. I give Minht Artistry permission to complete the beauty treatment. Terms & conditions for appointments * The technician will explain each step of the procedure during the service. * If an allergic reaction does occur I will seek medical attention immediately. * I must keep my eyes closed during any eye procedure(s). * Retention of eyelash extensions is dependent on each individual and their natural lashes, skin type and aftercare. * If I do not follow the correct aftercare procedure then the service may no longer be available to me. * A $50 non-refundable booking fee is required for all Fullset of eyelash extensions and a $30 non-refundable booking fee for all refills of eyelash extensions and other services. * A cleaning fee of $10 will be charged if I arrive to my appointment with mascara, makeup or moisturiser on. * A $30 fee or $50 fee (Fullsets only) will be charged if I cancel or reschedule within 24hrs of my appointment time and/or I do not attend my appointment. This fee will need to be paid before another appointment can be scheduled. * I agree for Minht Artistry to take photos for marketing, advertising and training purposes. * If I am more than 15 minutes late to my appointment, the appointment will be cancelled and a cancellation or rescheduling fee will be charged before another appointment is made. COVID Agreement * I have not been overseas in the last 4 weeks. * I have not been in contact with anyone who has been interstate or overseas in the last 4 weeks * I do not have any cold or flu symptoms. I agree to the terms & conditions for booking appointmentsCAPTCHACommentsThis field is for validation purposes and should be left unchanged.