Name *

First Name

Last Name

Phone *

(###)

###

####

In the last year, I have had...

(please check all that apply)

my hair professionally colored.

my hair box dyed.

my hair permed or relaxed.

You may request a patch test 24–48 hours prior to any coloring service to check for potential allergic reactions. *

I understand and will be requesting a patch test.

I understand and am opting out of a patch test.