Tomoko Shima Hair Salon

Consultation form

Name:

Phone number:

Email Address:

1.Have you ever had any reactions to chemical or cosmetic procedures? (please answer Yes/No)

If yes, Please Explain:

2.Please list any skin, scalp or all ergicconditions:

3.Please list any medication you are currently taking:

4.Please list all previous (up to 3yr history) or current chemical processes:

Permanent Wave

Date of service:

At home or professional:

Single Process Color

Date of service:

At home or professional:

Highlights

Date of service:

At home or professional:

Straighteners or Relaxers

Date of service:

At home or professional:

5.Are there any other special needs or considerations you would like the stylist to know about?