Secure New Client Intake Form

New Client Intake Form

Help us get to know you better so that we can serve you better!
Full Name*

First NameLast Name
Mobile Number*
E-mail*
example@example.com
How did you hear about us?*
Referral:
Other
How often do you utilize Salon Services?*

0-2/month1-3/quarter2-3/semi-annually3-5/yearOther
Services Performed?*
Which option would you say most reflects your life style?*
Do you exercise consistently?
Workout Frequency?
Do you perspire heavily in your hair?

Chemical Treatment History
Have you ever or currently receive the following Chemical services? Please answer to all that apply.
Relaxer - How often? / Brand?
ie, Every 2 months / Affirm
Last Relaxer Application:
MM/DD/YYYY or ## months ago or ## years ago
Permanent/Jerry Curl - How often? / Brand?
Last Permanent/Jerry Curl Application:
Texturizer - How often? / Brand?
Last Texturizer Application:
Permanent Haircolor - How often? / Brand?
Last Haircolor Application:
Semi/Temp/Rinse Haircolor - How often? / Brand?
Last Semi/Temp/Rinse Application:
Bleach/Lightener - How often? / Brand?
Last Bleach/Lightener Application:
Hi-Lites - How often? / Brand?
Last Hi-Lite Application:
Low-Lites - How often? / Brand?
Last Low-Lite Application:
Do you have any personal concerns about chemical services you would like to make the stylist aware of?*

Goals & Expectations
What are your hair goals?*
What are your expectations of the stylist?*
I affirm and understand that the above information will be kept confidential and is accurate to the best of my knowledge. I hereby certify that the information given and completed on this client intake form is true and the techincian will not accept any liability if the information I have provided is incorrect or inaccurate.
Type your full name to confirm your agreement with the above affirmation. *
Enter your initials to confirm you have read the Salon Policy and agreed to adhere to COVID19 Procedures.
(Right click on the link and open in new tab to prevent the loss of input.)
I have read the Salon Policy.*
I agree to adhere to COVID19 Procedures.*

New Client Consultation
The Client Consultation is an opportunity to establish a relationship between salon staff, stylists, and technicians with a new client. This time is used to learn the client’s likes and dislikes, needs, requirements, and goals. The technician is able to collect important information about past experiences, lifestyle, and health concerns that may affect the integrity of their hair and/or the outcome of the services rendered. Hair history, hobbies, side effects, preferred services, and alternative protective style options are discussed during this time. Salon services and products carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries due to exposure to certain chemicals and allergens used in the product ingredients. Exposure to said product ingredients may be reduced, replaced, or completely avoided due to information provided during the Client Consultation. In order to better serve the client and meet their individual needs, the Client Consultation is required and can not be waived. New clients must book a consultation scheduled prior to their desired appointment. You may book online or call (770) 870-6265.

In consideration of my use of Health In Hair & Wellness Hair Loss Center for general salon services, all chemical services, hair extension services, braiding services, product use within the salon during servicing and recommended home care hair products, implements, and other retail items;

I, do hereby release, waive, discharge, and covenant not to sue Health In Hair & Wellness Hair Loss Center, its owner, trustees, directors, officers, employees and agents from liability from any and all claims resulting in personal injury (chemical burns from relaxers or color services), illness (ie. allergic reaction to products), or damage to the hair arising from use of Health In Hair & Wellness Hair Loss Center products and services.

I have read the previous paragraphs and I know, understand and appreciate these and other risks that are inherent in the activity I am participating in. I hereby assert that my decision to undergo services and treatments is voluntary and that I knowingly assume all such risks.

Acknowledgement of Understanding:

I have read this waiver of liability and fully understand its terms. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.
Enter your Full Name to confirm your Acknowledgement of Understanding *
Date

MonthDayYear
Date

Submit New Client Intake Form

Submit your payment here.*

New Client DepositThe New Client Deposit.

$50.00

Subtotal

$0.00

Tax

$0.00

Total

$0.00

Credit Card

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