Presley Poe Consultation Application

Client Questionnaire

Thank you in advance for filling this out thoroughly and honestly. Because I value your time and money, this consultation application will help us determine if we are a compatible fit to help you achieve your hair goals.
Name*

First NameLast Name
Date of Birth*
MM/DD/YYYY
Pronouns
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Email*
example@example.com
How did you hear about me?*

Social Media (Instagram, Facebook, etc)Online SearchReferralOther
If referral, please list name:
What's your Instagram?
This isn't necessary, but we'd love to get feel for you, your lifestyle and what your lived-in hair looks like. Plus, we'd love to follow you! Find us on Instagram as @GoldStudioExperience
Medical History
Please list any known allergies:*
If none, please write "None."
Please list any current medications:*
If none, please write "None."
Are you pregnant or taking prenatal vitamins?*

YesNo
Have you ever experienced sensitivity to lightener?*

YesNo
If yes, please explain:
Have you ever experienced hair loss, thinning, breakage or bald spots?*

YesNo
If yes, please explain:
Your Hair Profile
What are your hair goals? *
Examples: Color, cut, length, texture, maintenance, etc.
Please upload an example of what you have in mind:
What do you like about this photo? Do you dislike anything?
What does your hair currently look like?
What are your hair care challenges?*

No volumeToo thickToo thinDrynessOilyDullBreakageFrizzinessWon't stay curledCurl managementNo challengesOther
What are you trying to achieve with your style?

VolumeMore curlsLess curvesStraightOther
What do you wish your hair did more of?
Preferred average visits to the salon:*

Every 2-4 weeksEvery 6-8 weeksEvery 2-3 monthsEvery 4-6 monthsOnce a year
How much time do you spend styling your hair after you wash it?

Less than 15 minutesUp to 30 minutesUp to 45 minutesMore than 1 hour
What is your home styling comfort level?

Very comfortableComfortableUncomfortableI want some tips!
What kind of styling tools are you using at home?*

Flat ironCurling ironBlowdryerNoneOther
Current Products
Shampoos & Conditioners:*
Styling Products:*
Heat Protectants:*
Other:
Hair History
Please provide a detailed description of your hair history for the last 3 years, including color, chemicals, bleach, treatments, etc:*
Have you ever used box color?*
Have you ever used henna color?*
Have you ever received a chemical straighter, relaxer service or similar treatment?*

Yes, within the last monthYes, within the last 6-12 monthsNo
Please go into more detail about any questions you may have for your stylist:
I understand that chemical services can result in hair damage such as breakage, color alteration and/or permanent change of texture. I agree to hold the salon and the hair technician harmless in the event of unexpected or undesired results. I understand that any further alterations or corrections will be provided at my own expense.*

I agree to these statements.
I understand that chemicals can damage my jewelry, clothes and/or accessories and I will dress accordingly for my appointment. I understand that the salon and the hair technician is not liable for any accidental damages.*

I agree to these statements.
I understand, have read and completed this questionnaire truthfully. I understand that previous treatments and/or chemical services can affect the outcome of my desired results. I have fully disclosed all requested information related to my hair history. I understand that withholding information or providing misinformation may result in contradictions and/or irritation to the hair service being received.*

I agree to these statements.
Signature*
Should be Empty:

Client Questionnaire

Medical History

Your Hair Profile

Current Products

Hair History