Hair by Niah Percia Client Intake Form

Hair by Niah Percia Client Intake Form
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Birthdate (Please note, I only work on clients ages 13+)

MonthDayYear
Date
Occupation
What is your hair type?

StraightWavyCurlyCoily
How would you describe the density of your hair?

FineMediumThick
How would you describe your scalp?

DryNormalOily
What is your current hair length?

ShortShoulder lengthMidbackLower back
Is your hair natural or relaxed?

NaturalRelaxed
How would you describe your hair?

HealthySlightly damagedDamaged
How often do you shampoo and condition your hair?

DailyEvery other dayWeeklyBi-weeklyMonthly
How often do you deep condition your hair?

DailyEvery other dayWeeklyBi-weeklyMonthly
What hair products/brands are you using?
What are your long term hair goals?
Have you ever had your hair colored before? If so, list when and any other details.
Please list any more hair history you would like to be noted.
Are you sensitive to or have you suffered a reaction from any hair/scalp treatments or chemicals?

YesNo
Are you currently taking any prescribed or over the counter medications?

YesNo
If yes please list here:
What is your stress level on a scale of 1-10?
What is your average daily water intake?
Please list the service(s) you are interested in.
Desired Appointment Date & Time: Please select the date & time you would like to come in. Operational hours are Tuesday through Friday. Selecting a date and time does NOT confirm an appointment. Niah will check for the next available appointment near your requested time slot.

MonthDayYear
Date
Hour MinutesAM/PM Option
Please upload a 2-3 photos of your natural hair. (good lighting, no bun photos)*

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Signature

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Date

MonthDayYear
Date