Client Intake Form

Client Intake Form
Client's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Client's Phone Number
Format: (000) 000-0000.
Client's Email Address
example@example.com
Occupation
Select an appointment
Select a hair service
Upload an image of hair style or hair color you prefer

You can upload multiple files here
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Upload an image of your current hair

You can upload multiple files here
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How often do you go to salon for hair treatment?

Other
How long is your hair?

Other
What is the current condition of your hair?

Other
What is the condition of your scalp?

Other
How often do you apply shampoo and conditioner in your hair?

Other
Have you use the following in your hair before?
When did you last visit a hair salon?

MonthDayYear
Date
When did you last apply professional or unprofessional color in your hair?
Are you taking any medications? If yes, please list them below:
Kindly list the hair products that you are using
What are the tools you are using to style your hair?
How did you hear about us?

Other
Any special instructions, comments, or suggestions?
This is a fill in the blanks field. Please add appropriate blank fields and text.
In order to secure your appointment, I must have a card on file to protect my time. Please include card number, expiration date, cvc, and zip code associated with card:
By signing below, I agree to the terms and conditions of the salon company.
Client's Signature
Date Signed

MonthDayYear
Date
Should be Empty: