Client Intake Form
Client's Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Client's Phone Number
Format: (000) 000-0000.
Client's Email Address
example@example.com
Select a hair service
Retwist (Ear Length)
Retwist (Above Shoulders)
Retwist (Shoulder Length)
Retwist (Mid-Back)
Retwist (Waist Length)
Scalp Detox
Hot Oil Treatment
Hydration Therapy
Starter Locs
Instant Locs
Wicks
Retwist and Style
Scalp Stimulation
Dandruff Treatment
Shampoo and Conditioning
Protein Treatment
Other
What hair style(s) do you like?
How often do you go to salon for hair treatment?
Every week
Every 2 weeks
Every 3-4 weeks
Every 2 months
Every 2-6 months
Twice a year
Once a year
Other
How long is your hair?
Short (Ear Length)
Medium-Short (Above Shoulder)
Medium (Shoulder)
Medium-Long (Mid-Back)
Long (Waist Length)
Other
What is the current condition of your hair?
Hair loss
Damage due to heat
Split ends
Breakage
Itchy scalp
Hair is dry
Dandruff
Other
What is the condition of your scalp?
Dry
Normal
Oily
Other
How often do you apply shampoo and conditioner in your hair?
Every day
Every other day
Twice a week
Once a week
Other
Have you used the following in your hair before?
Permanent hair color
Keratin Treatment
Razor cut/Thinning
Henna
Beeswax
Threading to combine locs
When did you last visit a hair salon?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
When did you last apply professional or unprofessional color in your hair?
Are you taking any medications? If yes, please list them below:
Kindly list the hair products that you are using
What are the tools you are using to style your hair?
Any special instructions, comments, or suggestions?
By signing below, I agree to the terms and conditions of the salon company.
Client's Signature
Date Signed
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Notes
Print Form
Submit
Should be Empty: