Client Information Form

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)

Cancel of
Please upload a pic of inspiration or of something you'd like to achieve

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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Client Intake Form