Re-Texturizing Consultation Form
This consult is for those interested in Japanese Straightening (also known as Thermal Reconditioning), Straight Variation, and the Curl Reformer.
Name
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First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
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Area Code
Phone Number
Have you ever had color, highlights, glaze, or henna in the last 5 yrs? If so, please describe below what service you've received and when.
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Have you ever had any texture altering service i.e. relaxer, texturizer, perm, Keratin treatment in the last 5 years? If so, please describe service received and when.
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Are you currently pregnant or can possibly be pregnant?
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YES
NO
Are you currently on any medication relating to high blood pressure, immune-deficiency diseases, cancer treatment, hormone altering medications (like birth control), Retin-A or are you vitamin deficient, enough to be treated with prescription vitamins? If so, please list type of medication you are currently taking.
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Have you had any surgery recently or procedures that warranted the use of general anesthesia? If so, when was the procedure performed?
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Month
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Day
Year
Date
Please upload current pics of your hair in its natural state from different angles- front, back, and side.
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I understand that a payment of $100 is due at the time of scheduling my appointment. This will be applied to my service. If for any reason I miss my scheduled appointment or fail to give 72-hour notice to change my appointment, I will forfeit my $100 deposit. All information disclosed above is true to the best of my knowledge. I understand that any previous chemical services were disclosed. I understand that all information given is important to ensure the best results and will be held in the strictest of confidence.
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I AGREE
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