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18
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1
Full Name
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First Name
Last Name
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2
Email
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3
Date of Birth
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Month/Day/Year
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4
Phone Number
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Please enter a valid phone number.
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5
Preferred Method of Contact
Text
Phone call
Email
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6
What service are you primarily interested in?
Medical Wig/ Cranial Prosthetic
Wig Install
Closure Install
Alopecia Braiding
Knotless Braids
Miracle Knots
Crochet Styles
Short Hair Cut
Cap Weave
Removable Cap Weave
I want you to make me a Wig
Silk Press
Sew-In
Scalp Treatment
Hair Growth Treatments
Unsure- I need guidance
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7
Are you currently experiencing any of the following?
*
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Hair Thinning
Alopecia
Breakage
Scalp irritation
Hairloss from a medical treatment
Traction Alopecia
CCCA
Dryness
Damaged Hair
Postpartum Hairloss
No major concerns
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8
How would you describe your lifestyle?
Low Maintenance
Busy professional
Active/Gym lifestyle
Glam/High Maintenance
Protective Styling Preferred
I need something Quick & Easy
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9
How often are you willing to maintain your hair?
Weekly
Every two weeks
Monthly
Minimal Maintenance Preferred
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10
What is most important to you?
Natural Appearance
Fullness & Volume
Hair Growth
Protective Styling
Scalp health
Convenience
Luxury Glam Look
Beginner Friendly Wig Option
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11
Have your worn wigs or hair systems before?
Yes
No
A little experience
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12
Would you like help with:
Insurance Reimbursement Information
Financing options
Wig Maintenance Education
Product Recommendations
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13
What investment range a are you comfortable with?
Under $250
$250-$350
$350-$700
$700-$1500
I’m looking for financing options
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14
Preferred Appointment Days
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Saturdays
Sundays
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15
Preferred Time
Morning
Afternoon
Evening
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16
Please upload photos of your current hair…
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Select files to upload
Max. file size
: 10.6MB
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Front, sides, back, scalp concerns.
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17
Hair Inspiration pictures
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Max. file size
: 10.6MB
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18
What type of experience are you hoping for?
Medical & educational Guidance
Luxury Beauty Experience
Fast & Convenient Styling
Hair Restoration Journey
Protective Styling Specialist
Braiding Services
Specialty Braiding
Not sure yet
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19
Please explain anything else we need to know,
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