Holistic Salon Head Spa Intake Form
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Allergies
*
Birth Month / Day
*
Emergency Contact
*
First Name
Last Name
Emergency Contact Number
*
-
Area Code
Phone Number
What digital resources have you already checked out?
*
Website
Instagram
Facebook
Google
Yelp
How did you hear about me?
*
Would you like a quiet appointment?
*
No thank you; I'd like to talk.
Yes please; I'd like to read.
Yes please; I'd like to relax.
Describe what you'd like to achieve during your visit today:
*
What services are you considering for the future:
*
What products are you currently using for shampooing and conditioning at home?
*
What product do you currently use for styling?
*
What are some of your primary concerns:
*
Which of the following have you experienced in the last year:
*
Thinning
Dry Hair
Breakage
Greasy Hair
Split Ends
Flakey Scalp
Scalp Irritation
Scalp Burning
Inconsistent Curl Pattern
Frizz
Lack of Volume
Damage
Have you ever colored your hair a home:
*
Yes, in the last 90 days
Yes, in the last 6 months
Yes, in the last year
Yes, over a year ago
Years ago or Never
Have you ever had an adverse reaction to hair color?
*
Have you ever had a haircut you weren't happy with?
*
Have you ever had a color service you weren't happy with?
*
Why did you leave your last hairdresser or why did you decide to try Holistic Hair Wellness?
*
How often do you prefer to come into the salon?
*
What is your anticipated budget for today:
*
Less than $100
Less than $150
Less than $200
Less than $250
Less than $300
Less than $350
Less than $400
$400+
Submit
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Should be Empty: