New Client Intake Form
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
*
Gender
*
Male
Female
Non-Binary
Email Address
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
When is the best time to reach you?
*
Emergency Contact Person
*
First Name
Last Name
Their Phone Number
*
Format: (000) 000-0000.
How did you hear about me?
*
Facebook
Twitter
Instagram
YouTube
TikTok
Google Search
Referred by a friend
Newspaper/Magazine
Online Advertisement
Other
Would you like to receive updates from me via email and or text?
*
Yes
No
How do you usually style your hair and how long does it usually take you or others to complete it?
*
What are things that you wouldn’t change about your hair?
*
What are things you would like to improve with your hair?
*
What product(s) are you using on your hair and what is their purpose?
*
Please list any allergies you have or may have.
*
Please list all medical conditions you have or may have now and or in the future.
*
Please list all medications you take.
*
Please upload a photo of your hair in its natural state.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload your first inspiration photo.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload your second inspiration photo.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Date Signed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Client's Signature
*
Save
Submit
Submit
Should be Empty: