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Healthy Hair
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Name
*
First Name
Last Name
Phone Number
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-
Area Code
Phone Number
Email
example@example.com
What is your Instagram handle?
Great! Now, What is your hair type?
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Straight
Wavy
Curly
Coiled
Please describe your hair density:
Please Select
1 Thin
2 Thin-Med
3 Medium
4 Med-Thick
5 Thick
Is your hair color treated?
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Yes
No
Is your scalp:
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Oily
Dry
Normal
How oily does your scalp get within two days of washing?
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Not Oily
Somewhat Oily
Very Oily
How often do you wash?
Every day
Every other day
Every 3-4 days
Once a week +
Is dandruff or flakiness an issue?
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Yes
No
Primary & Secondary Concern
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Dry
Limp
Frizzy
Brittle (breaks easy)
Damaged from heat
Thinning
Receding (receding hairline)
Damaged at the ends (split ends)
Chemically over-processed
Color enhancing
Volumizing
Other
How often do you apply heat?
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Never
Once a week
2-3 times a week
Daily
How do you prefer to style your hair?
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Air-dried and styled
Blow-dried and styled
Only air-dried
Only blow-dried
Other
Are you currently taking medication or in the last 60 days?
Yes
No
Other
What products do you use to style your hair?
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What is your biggest concern?
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What are your ultimate hair goals?
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We provided patch testing for all chemical and color treatment hair.
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I agree to patch testing
I disagree to patch testing
Acknowledgment:
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I understand that it's a possibility that I won't get my desired color look in one day.
I understand that My desire hair color look can be denied due to the state and condition of my hair.
Signature
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