New Client Consultation Form

KSS Hair Care Client Intake Form

Department: Hair and Barber
Date*

MonthDayYear
FemaleMale
Name*

First NameLast Name
Date of Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Website / Online SearchYelpFacebookReferralOther
If Referral, please list name
If Other, please let me know
Emergency Contact (EC)
EC Phone Number

Area CodePhone Number
Your Hair
ShortEar LengthShoulder LengthMid-back LengthLower-back + LengthBald
YesNo
DryNormalOily
HealthySlightly DamagedDry/Damaged
DailyWeeklyBi-weeklyMonthly
DailyWeeklyBi-weeklyMonthly
DailyWeeklyBi-weeklyAs NeededNever
StraightWavyTexturedDon't Know
FineMediumThickDon't Know
YesNo
Are you currently taking any medication that has side effects that can cause hair thinning and/or hair loss? If so, which one(s)?
More LengthMore MoisturePermanent ColorManageabilityOther
Daily RegimenHair ProductsEating HabitsWater IntakeOther
Date of your last visit to a hairstylist or barber:
Razor/Wet ShaveElectricOther
YesNo
Your Health
Are you currently taking medications? If so, please list:
ArthritisAsthmaAuto-Immune DisordersCancer / Systemic DiseaseDiabetesEczemaEpilepsy / Seizure DisorderHeadaches / MigrainesHead LiceHeart problemHepatitisHigh Blood PressureHIV/AIDSHormone ImbalanceLupusPsoriasisSclerodermaSickle Cell AnemiaOtherNone
If you checked yes to any of these please provide further information. If not mark N/A*
YesNoNo, not Applicable
Please list any known allergies including food, medicines, scents, plants, etc.:
By signing below, you attest that you have provided accurate and current information on this form and answered all medical and health-related questions truthfully and completely. Your signature also certifies that you understand that Karline's Salon and Spa reserves the right to deny service to any client due to a health condition he or she has that may pose a potential risk to practitioners or other clients, including those that pose a risk of potential contamination to service areas. Furthermore, signing below verifies that you understand that you are responsible for informing Karline's Salon and Spa and/or its stylists of ANY and ALL changes to your health condition as regards any question on this form or any potential public health risk that may arise from any change in your health condition. You acknowledge and accept that withholding information or providing misinformation may result in contraindications and/or irritation to the hair and scalp from treatments received. The treatments you receive here are voluntary and you release this hair care professional and Karline's Salon and Spa from liability and you assume full responsibility thereof.
Sign and Date*

Clear
Consent to Treatment of Minor: By signature below, I also hereby authorize Karline's Salon and Spa to administer service(s) to my child or dependent as they deem necessary.
Signature of Parent or Guardian and Date

Clear
I understand the reservation and cancellation policies at Karline's Salon and Spa and consent to my credit card on file being charged if I fail to show for my appointment or to give 24 hour notice for appointments scheduled Tuesday through Friday and/or 48 hours notice for Saturday or private appointments. In the event a credit card is not on file, I agree to the addition of a $25.00 fee assessment on my next appointment.
Should be Empty:

KSS Hair Care Client Intake Form

Your Hair

Your Health