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Birthday
Month
Day
Year

Answer the following questions with a YES or NO. Are you currently or have you ever suffered from the following?

Alopecia Areata
Yes
No
Chemotherapy hair loss
Yes
No
Trichotillomania (Stress or anxiety- urge to pull or tug on your lashes)
Yes
No
Thyroid condition treated with medication
Yes
No
Eye infection
Yes
No
Mechanically damaged lashes
Yes
No
Allergies to adhesive or adhesive ingredients
Yes
No
Recent eye procedure or surgery
Yes
No
Poor lash health, including short, this, or fragile lashes
Yes
No


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