Client Intake Form
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
What type of service or services are you looking for?
Color Service
Platinum Blond
Wash, Cut & Style
Corrective Color
Hair Extensions
Hair Botox
Facial Waxing
Other
Other
How often do you wash your hair?
Everyday
Every other day
Twice a week
Once a week
Please indicate the status of your scalp
Normal
Dry
Oily
Dandruff
Scabby
Other
How long is your current hair?
Short
Medium (Between bottom of ears and shoulders)
Long (Shoulders to bra strap)
X-Long (Past bra strap)
Please indicate the status of your hair. (Can select more then one)
Healthy
Damaged
Dry
Straight
Fine
Thick
Wavy Curly
How often do you go to the salon?
Once a week
Every 3-4 weeks
Every 2-6 Months
Twice a year
Once a year
Please upload a pic of your current hair. (Please make sure it's clear and in proper lighting)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload a pic of inspiration or of something you'd like to achieve
Browse Files
Drag and drop files here
Choose a file
Cancel
of
When did you last color your hair? Was it done by a professional or at home?
Please indicate a list of hair products you have or been using in the past year.
Are you experiencing or have experienced any hair loss?
*
Yes
No
* If yes please indicate when
Do you have city water or well water at home when washing your hair?
*
City Water
Well Water
Both (Incase you are back and forth between two places)
Are you going through Menopause
*
Yes
No
Are you currently taking or have been on any of the following medications/drugs in the past year? (Reason I ask is because should a chemical service be performed I would like to eliminate any risks to possible reactions)
*
Thyroid
Anesthetic
Blood Pressure
Cholesterol
Heart
Hormone Replacements
Birth Control
Antidepressants
Acne
Anticlotting
Immune Suppressants
Cancer
Epilepsy
Mood Stabilizers
Steroids
Weight Loss
Chemotherapy
Anti-Inflammatory
Antibiotics & Antifungal
NONE OF THE ABOVE
*
I confirm that all information provided is true and accurate. All information provided will remain confidential in accordance with the law and PIPEDA Act.
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