Your Information

New Client Intake Form
All About You!

Help me get to know you before your appointment!
Your Name

First Name Last Name
Birth Date

Month Day Year
Gender

Female Male Other
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
How did you hear about AtomicApril Hair Studio?

Website / Online Search Social Media Referral Magazine, Advertisement. Other
If you were referred, who referred you?

First Name Last Name
Service you are booked for:
Hair History

If you are unsure if any apply to you, please check box and put notes in box provided below.
Please check any of the following that apply

I have a sensitive scalp I have thyroid issues I have hair dye on my hair from dyeing my hair at home. I take heart medication I have hair dye on my hair from dye in a salon I wear extensions/have worn in past 6 months I Have Had a Chemical Straighter (Keratin or Brazilian Blowout, Perm) I have/ had a medical condition that affects my hair, scalp, hair product sensitivity. Ive bleached my hair in the past 2-3 years Ive bleached my hair in the past year I have never had hair color on my hair ever. My hair sheds exessively My hair is very dry and brittle My hair has lost its luster My hair is excessively oily I have dryness, dandruff or flakes. Other
If you checked any of the boxes above, please provide further information.
Is there any other condition or information you would like to share about your hair and/or beauty vision that you would like to achieve?
What do you LOVE about your hair? What would you like to see different?
Should be Empty:

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New Client Intake Form

All About You!

Hair History