Atomic Orchard Extensions Consultation

1
Name
First Name
Last Name
2
Email
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3
Phone Number
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4
Address
Street Address
Street Address Line 2
City
State / Province
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Other
Country
5
Date
Date
Year
Month
Day
6
Parental consent If under 18.
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7
How did you hear about us?* This field is required.
Facebook
Instagram
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Referral
Other
8
Why do you want hair extensions? * This field is required.Please be specific
Huge
Large
Normal
Small
Ok
Ok
9
Are you wanting a more temporary solution, or something that will last as long as possible?* This field is required.
Temporary Solution
As long as possible
10
How often are you willing to maintain your extensions?* This field is required.
every 6 weeks
every 8 weeks
every 12 weeks
11
Do you have an extension method in mind?* This field is required.
12
How long do you want your hair to be?* This field is required.select all that apply
collar bone length
mid back length
lower back
more volume
13
What is your long term goal for your hair?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
14
Have you worn extensions before?
YESNO
15
What type were they?
16
When were they installed?
17
How long did you wear them for?
18
Was it a good or bad experience?
Good
Bad
19
Have you experienced excess hair loss or damage to your natural hair due to a hair extensioninstallation? If yes, please elaborate.
Huge
Large
Normal
Small
Ok
Ok
20
What is your daily hair care routine?* This field is required.
21
How often do you wash your hair?
22
Do you use Dry Shampoo?
YESNO
23
What products do you use in your hair? * This field is required.Be specific
24
Do you blow dry your hair or style it with heat appliances?* This field is required.If so, how often?
25
How often do you cut your hair?* This field is required.
26
Do you color, perm, or chemically straighten your hair? * This field is required.If so how often?
27
What chemical procedures have been performed to your hair in the past 3 years?* This field is required.
28
Do you feel confident in styling your own hair?
YESNO
29
Have you ever damaged your hair from using hot tools or excessive blow drying?
YESNO
30
Are you currently taking any medications, or under a physician's care? * This field is required.If yes, please list all medications
Huge
Large
Normal
Small
Ok
Ok
31
Are you taking any new medications? Any that promote hair loss, hair growth, or shedding?* This field is required.
32
Have you suffered with or been diagnosed with Alopecia?* This field is required.
YESNO
33
Have you ever experiencedTraction Alopecia?* This field is required.
YESNO
34
Have you suffered or been diagnosed with Thyroid issues?* This field is required.
YESNO
35
Have you been ill, undergone surgery, been in a serious accident, or given birth in the last year?If yes, please explain
36
Do you have an scalp lesions?* This field is required.
YESNO
37
Do you suffer from excessive oil or dandruff?* This field is required.
YESNO
38
Do you have Psoriasis or Eczema?* This field is required.
YESNO
39
Do you have any allergies?* This field is required.(ie. latex, plastic, adhesives)
40
Do you have a sensitive scalp?* This field is required.
41
Are you exposed to or have you experienced Lice within the last 6 months?* This field is required.
YESNO
42
Do you sunbathe or use tanning beds?* This field is required.
YESNO
43
Do you use tanning sprays or lotions?* This field is required.
YESNO
44
Do you have any holidays planned in the next 6 months? * This field is required.if yes: will it be somewhere tropical?
45
What are your special interests or hobbies?* This field is required.
46
Do you swim?* This field is required.
YESNO
47
Do you participate in hot yoga?* This field is required.
YESNO
48
How often do you like to change your hairstyle or color?* This field is required.
49
Do you have hard water, or well water at home?* This field is required.
YESNO
50
Do you have any questions or concerns you would like to address during the consultation?* This field is required.
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Normal
Small
Ok
Ok
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