Client Consultation Form
Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Do you suffer from eczema on your head?
*
Please Select
Yes
No
Do you suffer from alopecia?
*
Please Select
Yes
No
Are you currently on any medication that may cause hair loss?
*
Please Select
Yes
No
Do you suffer from psoriasis on your head?
*
Please Select
Yes
No
Do you have a sensitive scalp?
*
Please Select
Yes
No
Are you allergic to any hair related products?
*
Please Select
Yes
No
If yes please give details
Are you allergic to metal?
*
Please Select
Yes
No
Are you pregnant or have given birth in the last 6 months?
*
Please Select
Yes
No
Do you regularly use a swimming pool?
*
Please Select
Yes
No
Have you had hair extensions fitted before?
*
Please Select
Yes
No
If Yes please state the method used and when the last time was
Currently your hair is?
Permed
Coloured
Straightened
None of the above
How thick is your natural hair?
Fine
Medium
Thick
Coarse
Afro
I would be happy for before and after pictures to be taken and used on Erika Swinn hair extensions website and social media?
Please Select
Yes
No
I agree to adhere to the aftercare conditions following completion of my treatment
Please Select
Yes
No
Signature
*
Continue
Continue
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