Hair Extension Consultation Form 2

Hair Extension Consultation Form

www.hairbyhs.com/new-client-extensions
Customer Information
Name

First NameLast Name
Age
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Were you referred to my Buisness? If so by who?

First NameLast Name
Appointment Date
Hair Condition

*This is just to give me a general idea on your overall hair health, this does NOT disqualify you from being able to receive extension services. Please be as thorough and honest as possible!
What is the length of your hair?
What is the color of your hair?
What is the current condition of your scalp?

NormalDryOilyScarsOther

Pre-procedure questions

	Yes	No	Remarks
Have you had hair extension before?
Do you have a medical condition wherein hair loss is present like alopecia?
Are you currently in treatment for hair loss?
Are you currently taking medication for hair loss?
Do you have any skin-related disease?
Do you have any allergies
Are you sensitive to metals?
Do you regularly swim?
Have you been pregnant for the last 6 months?
Do you usually go to gym for a workout?
Are you wearing an eyeglass?

Please upload 2-3 images of your current hair. Please, use good lighting and get the front and the back of your hair.*

Cancelof
Please upload 2-3 images of the hair that you want or your inspiration!*

Cancelof
Acknowledgment
- I confirm that all information I entered in this form is accurate and true.
- I understand that I need follow pre-procedure and post-procedure care.
- I understand that for cancelation or rescheduling, I need to call the salon or clinic directly and talk to the staff to get voice confirmation.
- I confirm that the clinic does not provide a refund for deposit payments.
- I released the salon for any liabilities or hold harmless for any damages, injury, or accidents that can happen during or after the procedure.
- I understand that removal must be performed by a hair salon technician or extensionist.
By signing below, you agreed that you have read and understood the terms and agreement above.
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Date Signed

MonthDayYear
Date
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Hair Extension Consultation Form