Client's Name
First Name
Last Name
Client's Phone Number
Format: (000) 000-0000.
Gender
Full Address
Client's Email Address
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Emergency Contact: Name + Number
Tell us about your hair and your hair goals:
What service are you interested in requesting?
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Upload an image of your current hair
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What is your current length?
Short-Ear Length
Shoulder Length
Lower Back Length
Mid-Back Length
Bald
Other
Is your hair naturally curly?
Yes
No
How would you describe your scalp?
Dry
Oily
Normal
How would you describe the current condition of your hair?
Healthy
Dry
Slightly Damaged
Damaged
What is the current condition of your hair?
Hair loss
Damage due to heat
Split ends
Breakage
Itchy scalp
Hair is dry
Dandruff
Other
How often do you apply shampoo in your hair?
Every day
Every other day
Twice a week
Once a week
Other
How often do you apply conditioner in your hair?
Every day
Every other day
Twice a week
Once a week
Other
How often do you apply deep conditioner in your hair?
Every day
Every other day
Twice a week
Once a week
Other
How would you describe the curl pattern of your hair?
Straight
Textured
Wavy
Don't Know
How would you describe the density of your hair?
Fine
Thick
Medium
Don't Know
Do you have now, or have had in the past, any problems with hair loss?
Yes
No
How often do you go to salon for hair treatment?
Every week
Every 2 weeks
Every 3-4 weeks
Every 2 months
Every 2-6 months
Twice a year
Once a year
Other
Have you used the following in your hair before?
Permanent hair color
Keratin Treatment
Razor cut/Thinning
Relaxer
Henna
When did you last visit a hair salon?
-
Month
-
Day
Year
Date
When did you last apply professional or unprofessional color in your hair?
Are you pregnant?
Yes
No
Please list any known allergies including food, medicines, scents, plants, etc...
Please indicate the list of hair products you're currently using:
How did you hear about us?
Facebook
Twitter
Instagram
YouTube
Online Advertisement
Google Search
Referred by a friend
Newspaper/Magazine
Other
In the context of your salon services, do you consent to Samel's Beauty Lounge taking and using before and after photos of your hair on our social media platforms? Please select your choice by marketing the appropriate box.
Yes, I consent to the use of my photos.
No, I do not consent to the use of my photos.
Yes, I consent, but please do not include any identifiable details.
Any special instructions, comments, or suggestions?
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