Hair Extensions Form
Name
First Name
Last Name
Date of birth
/
Month
/
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
Format: (000) 000-0000.
Email
example@example.com
Have you had extensions before? If Yes, please describe your extension history
Which method of hair extensions are you interested in?
Invisible bead extensions
Keratin bond
Tape in
Not sure
Are you taking medication that affects your hair growth?
Yes
No
Do you suffer from Eczema or Psoriasis?
Yes
No
Do you have and itchy or sensitive scalp?
Yes
No
Have you ever suffered from Alopecia or any type of hair loss?
Yes
No
Other
Have you ever had Chemotherapy?
Yes
No
Other
Are you or could you be pregnant?
Yes
No
Have you given birth within the last 6 months?
Yes
No
Do you suffer from health problems that may cause extensions to be unsuitable?
Yes
No
Not sure
Do you suffer from greasy hair?
Yes
No
Do you exercise regularly?
Yes
No
Other
Do you use saunas or steam rooms?
Yes
No
Do you wear protective head gear (i.e helmets)
Yes
No
Other
Do you wear glasses?
Yes
No
Do any products cause your scalp to itch, become dry or greasy?
Yes
No
Other
Do you have any allergies? If yes please explain:
Do you prefer a virtual or in-person consultation?
Additional comments/questions:
Submit
Should be Empty: