New Client Intake Form

New Client Intake Form
What is your full name?*

First NameLast Name
What is your email address? *
Please note, I will be reaching out by email to let you know which appointment to book and confirm your appointment.
What is your Birthday?

MonthDayYear
Month and Day
Phone Number*
Please note- I will respond by email and text to confirm your appointment.
What is your mailing address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your Instagram Handle?
How did you hear about me?*
What digital resources have you already checked out?*

WebsiteInstagramFacebookGoogle
Describe what you would like to achieve during your first visit today:
What services are you considering in the future?*
What are some of your primary hair concerns:*
What products are you currently using for shampoo and conditioner at home:
Which of the following have you experienced in the last year? Select as many as apply.*

ThinningDry HairBreakageGreasy HairSplit EndsFlakey ScalpScalp Irritation/BurningInconsistent curl patternsFrizzLack of VolumeDamage
Have you colored your hair at home:*

Yes, in the last 90 daysYes, in the last 6 monthsYes, in the last yearYes, over a year agoYears ago/ never
Have you ever had a haircut or hair color you weren't happy with?
How often do you prefer to come into the salon?
Have you ever had an adverse reaction to hair color?
What is your anticipated budget for today?

Less than $100Less than $150Less than $200Less than $250Less than $300$300 +
Should be Empty: