Contact 1 — Peaches and Curlz, Hair Boutique

Gina Curl Form

Name

First Name

Last Name

Phone

(###)

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Email

5-Year Chemical History:

Please provide a list of any chemicals used (e.g., relaxers, henna, keratin treatments, hair coloring and volume of developer used, highlights, texturizers, etc.) used on your hair in the last 5 years along with the date.

Date

MM

DD

YYYY

Chemical History

Date

MM

DD

YYYY

Chemical History

Date

MM

DD

YYYY

Chemical History

Date

MM

DD

YYYY

Chemical History

Date

MM

DD

YYYY

Message

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