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 
• Chemotherapy 
• 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 
• Antidepressants 
• Anticoagulants
• 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:_______________________________