Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
*
Date of birth
*
-
Month
-
Day
Year
Date
Hair Type
*
Curly
Wavy
Straight
Smooth
Relaxed
Straight
Condition of your hair ...
*
Normal
Dry
Very dry
Damaged
Your scalp is...
*
Oily
Dry
Normal
Itchy
Flaky
Other
What do you like most about your hair?
*
What do you like least about your hair?
*
How does your hair feel?
*
Would you like more information on how to care for your hair at home?
*
Yes
No
Is your hair as healthy as you would like?
*
Yes
No
Do you have concerns about thinning hair?
*
Yes
No
Are you on any medications?
*
Yes
No
Do you suffer from any allergies?
*
Yes
No
Do you take any vitamins?
*
Yes
No
What hair products are you currently using?
*
How often do you visit the salon?
*
When was your last visit?
*
How often do you wash your hair?
*
How much time are you willing to spend on your hair?
*
Styling method
*
Braids
Weaves
Blow drying
Heat styling
Other
Would you be interested in a detailed explanation of what products I recommend and how they will improve the condition of your hair?
*
Yes
No
Send
Should be Empty: