Form
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
What is your hair type?
*
Wavy
Curly
Coarse
Straight
Other
What is your hair texture?
*
Fine
Medium
Thick
What is your hair length?
*
Pixie
Long
Short
Very long
Shoulder
How often do you wash your hair?
*
Daily
Once a week
Every other day
Twice a week
What is your scalp type?
*
Oily
Dry, itchy, flakey
Oily with dandruff
Normal
Does your hair frizz?
*
Yes
No
How often do you use heat tools?
*
Everyday
Once a week
Every other day
Never
Other
Is your hair dry or damaged?
*
Dry
Damaged
Both
Neither
Do you suffer from balding/extreme hair loss?
*
Yes
No
Is your hair color treated?
*
Yes
No
How do you style your hair?
*
Air dry
Blow dry
Do you have split ends?
*
Yes
No
What are your hair concerns?
*
What are your hair goals?
*
How would you like to be contacted?
*
Text
Call
Email
DM
Other
I’m interested in....?
*
Business
Products
Both
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