Appointment Request Form
Full Name
First Name
Last Name
Contact Number
Please enter a valid phone number.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What date and time work best for you?
Any other specific date and time, if the above selection is not suitable.
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Month
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Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
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Health Profile
To ensure the best hair care, kindly furnish responses to the health-related questions presented below.
1. How would you describe your overall health and well-being?
2. Are there any specific medical conditions or concerns we should be aware of before providing in-home hair care and manicure services?
3. Are you currently taking any medications? If so, please provide a list.
4. Do you have any allergies to beauty or personal care products?
5. Have you experienced any adverse reactions to previous hair care or manicure treatments?
Type a question6. Are there any mobility challenges or physical limitations we should consider during the service?
7. Do you have a preferred schedule for in-home hair care and manicure sessions?
8. Is there a specific hairstyle or manicure style you prefer?
9. Are there any specific tools or products you would like us to use or avoid?
10. How would you like us to communicate with you regarding scheduling and any changes to appointments?
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