Customized Hair Form
We are Modern Nature! Bringing you the ultimate combination of both Nature and Science, which together, creates the first and only anti-aging clinically tested hair care line in the world! No silicones, sulfates, parabens or harsh chemicals! Gluten free, vegan and LEAPING BUNNY approved!
Name
*
First Name
Last Name
Email
example@example.com
What is your Instagram handle? (if you prefer that)
How did you find this hair quiz?
Facebook
Instagran
YouTube
A friend sent me it
What do you consider your hair to be?
*
Straight
Wavy
Curly
Other
If wavy or curly, what do you interpret your pattern as?
2A
2B
2C
3A
3B
3C
4A
4B
4C
Has your hair been chemically treated?
*
Relaxed
Transitional
Permed
None
Has your hair been colored?
*
Yes
No
What color are you trying to maintain?
*
Platinum Blonde
Golden Blonde
Brown
Red
Black
Other
If curly, do you wear protective styles? If so, what kind and how often?
What would you consider your roots to be?
*
Oily
Dry
Normal
Combination of both oily and dry
Is your scalp dry?
*
Yes
Yes, and flaky
No
Are you shaft and ends...?
*
Dry
Normal
After washing your hair, do you...?
*
Blow Dry
Air Dry
Diffuse
How many times a week do you wash your hair?
*
1-2 times per week
1-2 times a month
Every other day
Every day
Can you briefly explain why you wash your hair the amount of times a week/month that you do? (Ex: oil, frizz, workouts, out of habit, work reasons, protective style, etc)
*
Do you have frizzy hair?
*
Yes!!
Yes, but not terrible
No
What is your favorite way to style your hair?
*
Sleek & Straight
Natural Curl
Heated Curls
Care free, I don't style my hair
Men's sculpting clay
Protective Styles
How many times a week do you apply heat?
*
0
1
2
3
4
5
6
7
What are your primary hair concerns?
*
Repair my color/chemical damage
Intense hydration for my dryness and dullness
Give volume and density to my hair
Fix my dry and flaky itchy scalp
Control frizz and flyaways
Balance my oily roots
Growth
Mend split ends
Help with thinning and balding
Tangles and knots
Hair loss
Adding silk and shine
Other
What is your MONTHLY hair product budget? (include shampoo, conditioner + leave-tin, styling products, etc)
*
$10-$20 a month
$20-$30 a month
$30-$40 a month
$40-$50 a month
$50-$60 a month
$60+ a month (obsessed with my hair care!)
What are your overall hair goals?
*
Do you have any allergies to plants, fruits or nuts? Or anyone in your household?
*
So I can better understand why your hai behaves the way it does, what current hair products (shampoo, conditioner brand) are you currently using? Are there any leave-ins or styling tool you like to use as well?
Submit
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