Hair Dye Allergy Test Form
Please complete this form to help us safely assess your sensitivity to hair dye products before your color service.
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Date of Patch Test
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Product Name/Brand Used for Patch Test
*
Have you ever had a patch test for hair dye before?
*
Yes
No
If yes, did you experience any reaction to previous patch tests?
No reaction
Mild redness/itching
Swelling/blisters
Other
Do you currently have any skin or scalp conditions?
*
No
Yes (please describe below)
Location of Patch Test (e.g., behind ear, inner arm)
*
Additional Notes or Observations
Submit
Should be Empty: