HairCraftClient Intake Form
PERSONAL INFORMATION
Name:
Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender:
Pronouns:
Address:
City:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone:
Format: (000) 000-0000.
Email:
example@example.com
How did you hear about me?:
Would you like to be added to the email list for updates & special offers?
Yes
No
MEDICAL HISTORY
Have you ever experienced hair loss?
Yes
No
If yes, please explain:
Do you experience alopecia or any conditions that impact your hair and scalp?
Yes
No
Do you have psoriasis/eczema/dermatitis affecting the scalp?
Yes
No
If yes, please specify:
Do you have a sensitive scalp?
Yes
No
If yes, please specify:
Do you have any allergies?
Yes
No
If yes, please specify:
Are you pregnant or breastfeeding?
Yes
No
Current medications (if any):
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HAIR CARE ROUTINE
Do you swim or go to the gym frequently?
Yes
No
How often do you wash your hair?
Daily
2-3 times a week
Weekly
How often do you color your hair?
When did you last color your hair (if applicable)?
How often do you cut your hair?
When was the last time you cut your hair?
Have you had any hair extensions done before?
Yes
No
Do you have any upcoming holidays booked?
Yes
No
LIFESTYLE
Occupation:
Interests / Hobbies:
Comfort preferences (music, scents, temp, etc):
Preferred topics:
By signing below, you agree to the following: The information provided on this form is accurate and up-to-date to the best of my knowledge. I release and absolve my hairdresser and HairCraft, from any liability for harm or injuries resulting from any misinformation provided on this form.
Client Name
First Name
Last Name
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hairdresser Name
First Name
Last Name
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Consultation Form
....HAIR GOALS & HISTORY....
Primary goal for today:
Long-term hair goals (3-6 months):
Hair color history (5 years):
Previous chemical history (relaxer, perms, keratin, etc):
At home hair care:
Lifestyle notes:
Concerns:
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