Customized Client Questionnaire
Name
*
First Name
Last Name
Date of Birth (For a fun gift every year)
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Phone Number
-
Area Code
Phone Number
Email (we do not share info. this form signs you up for our loyalty program)
*
example@example.com
How did you hear about Kalladora?
*
Website / Online Search
Yelp
Facebook
Referral
Other
If Referral, please list name
If Other, please let us know how you heard about Kalladora.
Your Kalladora - Gift of Beauty Profile
Sis, we are a MOVEMENT, inspiring women in all things beauty! Whether it is creating skincare goals, the WONNET hair protection tool, foodie discoveries, inspirational reading and collaborating through chats, affirmations, and Bible study. We're all about inspiring the transformation of Christian women, focused on who God has purposed and Graced us to be, its a journey we hope you'll join us!
Tell us about yourself? What are your interests - Skincare, Hair protection, Kalladora Girl time - Bible Study?
*
*Professional skincare consultations by licensed esthetician/educator - Rheanita Gammon-Reese.
What is skin type?
*
Normal
Dry and/or Dehydrated
Oily
Combination
Sensitive
I don't know
Other
What are your skin concerns or issues?
*
Pigmentation, Uneven skin tone, Sun Damage
Post acne scarring and/or uneven skin texture
Acne, break out prone * includes teen and adult
Age management - fine lines, wrinkles, loss of elasticity
Sensitized - redness
Other
Hair protection - The WONNET is a customized hair protection accessory - satin lined with your choice of hair added to the lining of the cap - hair styled protection for the woman on the GO! Available in various colors and hair styles and textures. Excellent option for hair loss conditions.
*
Yes, show me more!
Sounds interesting, send me more information.
Hair protection interests/concerns
Current hair styling/protection routine_____________________________________
Hair loss conditions, if so what type of medical condition?___________________
Other
Would you be interested in joining a group of women for a weekly virtual Bible Study?
Would you like to receive our week Affirmation of Grace?
*
YES, sign me up!
NO
Regarding skincare consultation: I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the professional skincare consultation/product recommendation/service provided.
*
Yes
Signature
*
Please take a couple skin and/or hair selfies!
What about this picture do you like?
Submit
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