DO YOU HAVE A COLOUR APPOINTMENT SCHEDULED? We need to check your sensitivity . Please complete this form ahead of your patch test.

Name

First Name

Last Name

Do you have sensitive itching, damaged scalp or rash on face?

Do you have any allergies or reaction to a tattoo, henna, black henna tattoo or permanent make-up?

Have you had any allergic reaction to any skin product or perfume?

Are you taking medication for any allergies?

Is it more than 6 months since you last applied a colour to your hair (self or professional) ?

Have you had a tattoo, henna, black henna tattoo or permanent make-up since the last colour?

Have you ever had any sort of reaction to any hair colour or bleach?

If you have had Covid 19 - Have you had increased sensitivity to anything since having Covid?

. If you have had the Covid 19 vacination, have you had increased sensitivity to anything since?

PLEASE NOTE

If the answer to any of the questions in this box is YES: STOP we cannot continue with a colour application. We suggest you seek medical advice about hair colouring before making your next appointment. If you have answered NO to all questions please sign, date and complete the final details on this form.

Date of your hair appointment

Date of your skin test

If you have had the Covid Vacine - please tell us when

SIGNATURE Write your full name in the box

Date of signature