Billionaires Barbershop

Chemical Service Consultation & Consent

Welcome to Billionaires Barbershop. Before receiving a chemical service, please complete this consultation to help your grooming professionals evaluate your hair scalp condition, review your chemical treatment history, and determine the appropriate precautions for your service. Please answer all questions accurately.

First Name

Last Name

Phone

Chemical Treatment & Safety History

Have you ever experienced an allergic reaction, burning, irritation or hair loss following a chemical hair service?

YES

UNSURE

Do you currently have any scalp irritation, sores, cuts, tenderness, or broken skin?

YES

UNSURE

Have you experienced any recent hair breakage, excessive shedding, or unusual hair loss?

YES

UNSURE

Have you ever received a chemical hair treatment, including relaxers, perms, hair colors, bleach, or chemical straightening?

YES

UNSURE

Do you have any known allergies or sensitivities to hair, color, relaxers, perms, or other hair product ingredients?

YES

UNSURE

Have you used box dye, henna, metallic dyes, or other at home chemical treatments on your hair?

YES

UNSURE

Client Acknowledgment & Consent

I confirm that the information provided is accurate to the best of my knowledge. I understand that chemical Hair services involve potential risk, including irritation, allergic reactions, hair damage, breakage, and unexpected results.

I understand that my Barber will review my consultation, evaluate my hair and scalp, and explain the proposed treatment and relevant risk before proceeding.

I agreed to inform my Barber of any additional concerns and understand that a chemical service may be modified, postponed, or declined for safety reasons.

I acknowledge that completing this consultation does not guarantee that the clinical service will be performed.

I have read and understand the information above and confirm that my answers are accurate

Name of Barber Performing Service

Client Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date of Consultation

Month

Day

Year

Billionaires Barbershop

Chemical Service Consultation & Consent

Chemical Treatment & Safety History

Have you ever experienced an allergic reaction, burning, irritation or hair loss following a chemical hair service?

YES

UNSURE

Do you currently have any scalp irritation, sores, cuts, tenderness, or broken skin?

YES

UNSURE

Have you experienced any recent hair breakage, excessive shedding, or unusual hair loss?

YES

UNSURE

Have you ever received a chemical hair treatment, including relaxers, perms, hair colors, bleach, or chemical straightening?

YES

UNSURE

Do you have any known allergies or sensitivities to hair, color, relaxers, perms, or other hair product ingredients?

YES

UNSURE

Have you used box dye, henna, metallic dyes, or other at home chemical treatments on your hair?

YES

UNSURE

Client Acknowledgment & Consent

I understand that my Barber will review my consultation, evaluate my hair and scalp, and explain the proposed treatment and relevant risk before proceeding.

I agreed to inform my Barber of any additional concerns and understand that a chemical service may be modified, postponed, or declined for safety reasons.

I acknowledge that completing this consultation does not guarantee that the clinical service will be performed.

I have read and understand the information above and confirm that my answers are accurate

Name of Barber Performing Service

Client Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date of Consultation

Month

Day

Year