Client Intake Form
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Health and Safety
Please select all of the following that apply to your current health and well-being
*
Allergies
Pregnant
Skin,Scalp, or Eye Conditions
Currently taking any Medications
Had a hair, facial, brow, lash, or nail service in the last 2 weeks?
I wear contact lenses
None of the above
Please explain in detail any of the above health and well-being concerns checked above, including but not limited to listing all applicable procedures, treatments, and medications below:
*
Services
Choose the services you would like to receive:
*
Hair Services
Eyebrows
Eyelashes
Nails
Facial
Date of Service
*
-
Month
-
Day
Year
Date
Range of Dates
Hair Services
What hair services are you getting? (check all that apply)
Cut
Color
Highlight/Balayage
Styling (wash/blowout)
Keratin/straightening
Texture service (perm/c waves)
Other
Other
Hair goals in simple terms (e.g., want softer waves, darkercolor, more volume):
Hair type (check one):
Straight
Wavy
Curly
Coily
Other
Other
Natural hair concerns to address during service:
Do you have a preferred length or style after cut?
Any sensitivities to dyes or fragrances? (yes/no; if yes, explain)
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Makeup
Skin type (check one):
Normal
Oily
Dry
Combination
Other
Other
Skin concerns you want addressed (acne, redness, dark circles, wrinkles, none):
Foundation shade or level (light, medium, dark; undertone if known):
Natural look or full glam? (natural/full glam)
Any colors you don’t want or need (lip, eye shadow, blush):
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Facial
Facial goals (clearing pores, anti-aging, hydrates, soothing, etc.):
Any allergies to products (fragrances, essential oils, specific ingredients)? (yes/no; explain)
Do you prefer fragrance-free products? (yes/no)
Yes
No
Any sensitivities to heat or steam? (yes/no)
Yes
No
Last facial date (approximate):
-
Month
-
Day
Year
Date
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Eyebrows
Brow shape you want (soft arch, strong arch, straight, natural, glam):
Brow color preference (match hair, lighter, darker):
Do you tweeze, wax, or thread, or both? (check all that apply):
Tweeze
Wax
Thread
Other
Other
Any shading, tint, or lamination requested (yes/no; explain):
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Eyelashes
Lash services requested (check all that apply):
Lash lift
Lash tint
Extensions
Lash clean-up
Other
Other
If extensions, length/volume preference (natural, medium, dramatic):
Any allergies to adhesives or lash products? (yes/no; explain):
Do you wear contact lenses? (yes/no)
Yes
No
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Nails
Service type (manicure, pedicure, both):
Manicure
Pedicure
Both
Nail health concerns (brittle nails, splitting, discoloration):
Brittle
Splitting
Discoloration
Other
Other
Nail length/shape preference (square, round, almond, stiletto):
Square
Round
Almond
Stiletto
Other
Other
Do you have any nail polish allergies? (yes/no; if yes, which ingredients?):
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Submit
Should be Empty: