New Client Intake Form

New Client Intake Form

Hair by Niah Percia
Name

First NameLast Name
Email
You will be contacted via email.
Phone Number
Please enter a valid phone number.
Birthdate (Please note, I only work on clients ages 13+)

MonthDayYear
Date
Occupation
What is your natural 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? Please note, as a natural specialist, I only accept transitioning relaxed clients.

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
If yes please list here:
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.*
Please upload a 2-3 photos of your natural hair. (good lighting, no bun photos)*

Cancelof
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: