HAIR EXTENSION CONSULTATION FORM
Please read and answered the following questions accurately and to the best of your knowledge.
How did you hear about us ?_________________________________
Have you ever had hair extensions applied? Yes No
If yes Why did you decide to remove them? _____________________________
Hair extensions may contain man-made fibers, plastics and acrylics and I am NOT allergic. Yes No
Do you have any known skin or scalp allergies? Yes No
Do you have frequent scalp irritation or itching ? Yes No
Do you have now,or have had in the past, problems with hair loss? Yes No
Are you willing to use the recommended shampoos and conditioners and follow after-care protocols? Yes No
Please circle any of the following that might apply to you:
- Eating disorders or Poor Nutrition
- Recent Childbirth
- Extreme Stress
- Thyroid Disease
- Hormonal imbalance
The following drugs may cause premature hair loss leading to dissatisfaction with your service. Please advise your professional if you are taking any of the following:
- Cholesterol Lowering Drugs
- Drug Derived from Vitamin A
- Parkinsons Medications
- Anticonvulsants (Epilepsy
- Ulcer Drugs
- Beta blockers for High Blood Pressure
- An arthritis Blood Thinners
Do you have any questions or concerns regarding your hair appointment today?
For Professional Use Only
Length – above chin above shoulders below shoulders
Tecture – straight wavy curly
Porosity – low average extreme
Density – light medium heavy
Scalp – dry normal oily
Scalp abrasions, or other observations:_____________________________________
Extensions type Desired:_________________________________
Extension Price per Bundle:__________________ x Bundles needed:______________________
Bead, Tape,or Adhesive Supplies:__________________________________
Total Non Refundable Deposit Required:_______________________________
Today’s Date:____________________ Installation Date:_________________________
Estimated Installation Cost, Due At Time of Service:_______________________________-
Please read the following statements and Initial next a them. Your initials confirm you have read agree to and understand This information.
___________ I agree to have hair extensions applied to my natural hair and/or removed and retouched. By signing this agreement. I consent to the placement and removal of the hair extensions by the certified hair extensions specialist.
___________ I understand that there are risks associated with having hair extensions applied to or removed from my natural hair. I further understand that as part of the procedure, irritation, itching, headaches or damage to my natural hair may occur.
_________l understand and agree to the after-care instructions provided by the hair extension professional realize are accept the consequences of failure to adhere to these instructions, as it may cause the hair extensions to fall out prematurely, cause hair damage, and/or decrease in The time the extensions will last. These after-care directions include:
Do not use shampoos that contain sulfur (such as a dandruff shampoo). Always shampoo with your head up, starting with your scalp and working your way through the ends, Keep conditioners away from the bond and always rinse conditioners thoroughly, brush your hair daily from scalp to ends with the recommended soft bristle brush. Pull hair back in a loose braid or ponytail while sleeping. Remember, it is natural to lose up lo 10% of your strands between Touch-ups (8-12) weeks Keep your strands and return them to your stylist.
________This agreement will remain in effect for this procedure and all future procedures conducted by the certified hair extension professional. I understand this agreement is legal and binding. I am over 18 years of age and consent to the agreement and treatment. I release my technician or salon(_______________) from all liability associated with this procedure, who is performed with the utmost attention to safety and proper application, using tools and products with this procedure the technician has been properly trained to use. There is no guarantee for the bonding time of the extensions.
By signing below, I verify that I have read and understand the above statements and agree to them Signature:____________________ Date:_______________________________