Pregnancy Intake Form

For clients who are pregnant or may be pregnant. Lash extensions are generally considered safe during pregnancy; this form helps document sensitivity, positioning needs, and physician advice.

Client Information

Full Name:

Date:

Phone Number:

Pregnancy Details

Weeks pregnant:

Due date (if known):

High-risk pregnancy? ☐ Yes ☐ No

Has your physician advised against prolonged lying on your back (supine positioning)? ☐ Yes ☐ No

Comfort & Sensitivity

Have you experienced dizziness, nausea, or shortness of breath when lying flat? ☐ Yes ☐ No

Increased sensitivity to fumes or products during pregnancy? ☐ Yes ☐ No

Other relevant notes (complications, sensitivities):

Positioning & Service

Acknowledgment & Consent

I have disclosed my pregnancy status and any relevant health information.
I understand that retention may vary during pregnancy due to hormonal changes and shedding.
I agree that comfort positioning may be used and that the service can be stopped at any time if I feel discomfort, dizzy, or unwell.

Client Signature:

Date:

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