hair loss form

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Color Intake Form
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
How did you hear about us

FaceBookTikTokInstagramFriendOther
When was your last color done

3-4 months5-6 months6 months +
Whats your hair history in the last 3 years
Please select all that you are wanting

Go lighterGo darkerVividsblond/PlatinumAdd dimension (Highlights/LowlightsBalayageBalance uneven colorGray covergeGray blendingGo cooler/AshierGo warmer
What date are you wanting to come in

MonthDayYear
Date
Signature

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