New Guest Extension/Topper Application Form

1
Name* This field is required.Please enter name that you prefer.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
City and State* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
How did you find Melinda?* This field is required.
Facebook
Instagram
LinkedIn
Referred by a friend
5
Who referred you so a “thank you” can be sent to them?* This field is required.
6
Have you ever had extensions/toppers before?* This field is required.
Yes
No
I have extensions in now.
I have a topper on now.
7
How would you describe your previous experiences with getting your hair done?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
8
What are you wanting in regards to extensions and toppers?* This field is required.
Extensions
Toppers
Both
Other
9
Please give more details.* This field is required.
10
When are you available most days?Topper applications can take 2+ hours and extension applications can take 5+ hours depending on the desired results. Please check day and times that apply.
9am-12pm
1pm-4pm
2pm-5pm
Tuesday
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Wednesday
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Row 1, Column 1
Row 1, Column 2
Thursday
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Row 2, Column 1
Row 2, Column 2
Friday
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Row 3, Column 1
Row 3, Column 2
Tuesday
Wednesday
Thursday
Friday
9am-12pm
Row 0, Column 0
1pm-4pm
Row 0, Column 1
2pm-5pm
Row 0, Column 2
9am-12pm
Row 1, Column 0
1pm-4pm
Row 1, Column 1
2pm-5pm
Row 1, Column 2
9am-12pm
Row 2, Column 0
1pm-4pm
Row 2, Column 1
2pm-5pm
Row 2, Column 2
9am-12pm
Row 3, Column 0
1pm-4pm
Row 3, Column 1
2pm-5pm
Row 3, Column 2
1 of 4
11
Maintenance for toppers is every 4 weeks and maintenance for extensions is every 8-10 weeks. Are you committed to the maintenance process?
YESNO
12
Hair Density Examples
13
Check the hair density/thickness that best describes your hair.* This field is required.
Extra Light
Light
Light/Medium
Medium
Medium/Heavy
Heavy
Extra Heavy
14
Hair Length Examples
15
Check the hair length that best describes your hair.* This field is required.
Ear Length
Chin Length
Shoulder Length
Armpit Length
Mid-Back Length
16
Are you in need of color services too?
YESNO
17
What did you have in mind to get done to your hair? Anything else you'd like to share?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
18
What financial investment are you prepared to make?Extension and Topper Services for hair loss with Melinda, on average, can cost anywhere between $800 - $2000. The final price of your service will vary greatly based upon the desired result. The price, including what to expect for maintenance, will be determined during the in-person consultation.
$600-$900
$900-$1200
$1200-$1500
$1500-$1800
$1800-$2100
$2100+
19
What does your hair look like today?Please upload an image of your hair today. If you are thinning on the top/crown, please show an image from the top view.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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20
What is the desired look after all services are complete?Please upload 3 images showing what you have in mind. Not all results can be achieved in one appointment. This will be discussed in the in-person consultation.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
21
Please verify that you are human* This field is required.
Should be Empty: