Belli Belli :: Salon San Diego

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Have used box color and/or DIY color within the past 3 years *

Yes

No

Do you have mineral deposits and/or well water at your home *

Yes

No

Do you have extensions if so did we do them *

Yes

No

Extensions installed at Belli Belli

Have you had corrective hair color within the past 3 years *

Yes

No

Have you gone light to dark within the past 3 years *

Yes

No

Have you had a perm and or relaxer within the past 3 years *

Yes

No

Are you currently on a prescribed medication *

Thyroid, chemotherapy, and hormone and other medications medications can effect receptivity and predictability of hair color and chemicals

Yes

No

Do you have any allergies we should be aware of *

Yes

No

Do you have any scalp/skin conditions that may be irritated during your service (ie psoriasis, acne, open soars)

Option 1

Option 2

Have you used henna or plant based hair color within the past 3 years *

Yes

No

Have you used metallic hair color within the past 3 years *

Yes

No

I understand that if I answered yes to any of the Hair History questions above that I will accurately communicated to my service provider/stylist before start of services *

Yes, I will communicate all Hair History to my stylist

Many times we will take before and after pictures for service outcome. Can we (stylist and or salon) post images on our social media? *

Yes

No

Please Print Name For Signature *

First Name

Last Name

Date

MM

DD

YYYY