Name
*
First Name
Last Name
Facebook
*
What is your Instagram @
*
Choose your service . If you are interested in one service or the other please only answer the questions the pertain to you
*
Extensions+Color
Extensions Only
Mesh
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Have you ever had extensions ?
If yes, when and what type?
*
During any of these services, did you experience excess hair loss or damage to your natural hair? If yes elaborate.
*
How long is your hair now?
*
What is your long term goal for your hair?
*
How long do you want your hair ?
*
What products do you use at home and how frequently?
*
Do you and how often do you get the following services?
*
How often do you like to change your style or hair color?
*
Have you been ill, had surgery or on any medication in the past 6 months or year?
*
Do you have any allergies?
*
Do you have any medical conditions that may Interfere with this service.
*
Are you presently experiencing an unusual amount of hair loss?
*
Preferred days and times for consultation and/or appointment
*
Any questions or concerns regarding the service?
*
Please upload Pictures of your current hair
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload pictures of your dream hair
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Do you have a medical diagnosis from a medical provider?
*
Are you aware of the financial investment of Mesh Integration?
*
Yes
No
Do you have medical insurance ? Would you like to see if you qualify for coverage under your insurance?
*
Please Attach Pictures of your current hair loss
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Attach Picture
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Attach Picture
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
By booking this consultation, you agree to be featured in our photo and video content, and you understand that all content we create belongs solely to Kelly Maxwell Hair Extensions for use across social media, marketing, and education.
*
Yes I agree
Submit
Should be Empty: