𝒆𝒙𝒉𝒂𝒍𝒆 Extension Consultation Form
Customer Information
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Hair Condition
What is the length of your hair?
What is the color of your hair?
What is the current condition of your scalp?
Normal
Dry
Oily
Scars
Other
Pre-procedure questions
Rows
Yes
No
Remarks
Have you had hair extension before?
Do you have a medical condition wherein hair loss is present like alopecia?
Are you currently in treatment for hair loss?
Are you currently taking medication for hair loss?
Do you have any skin-related disease?
Do you have any allergies
Are you sensitive to metals?
Do you regularly swim?
Have you been pregnant for the last 6 months?
Do you usually go to gym for a workout?
Are you wearing an eyeglass?
Please upload an image of your current hair
Please upload an image of the hair that you want or your inspiration
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
Submit
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