Customer Profile Information
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Birthday MM/DD
Wedding Anniversary MM/DD
Occupation
Tell me any issues or concerns you are having with your hair...
Do you have any Medical Conditions?
Any medications/vitamins you take?
Is your texture/density.....
Fine
Medium
Coarse
Is your hair.....
Natural
Relaxed
Transitioning
If relaxed, how often do you receive a touch-up?
Do you relax your hair at home?
Yes
No
When was your last relaxer?
Do you shampoo/condition hair at home?
Yes
No
If yes, what kind of products do you use?
How often are you shampooing/conditioning?
How often are you deep conditioning?
How often do you receive a trim?
Do you work out?
Yes
No
If yes, what do you do with your hair while working out?
Is your hair colored?
Yes
No
If yes, is your hair color....
Permanent
Rinse
When was your last color service?
Please Rate the following of Importance.......
Long Hair....
1
2
3
4
5
Least Important
Very Important
1 is Least Important, 5 is Very Important
Healthy Hair
1
2
3
4
5
Least Important
Very Important
1 is Least Important, 5 is Very Important
Stylish Hair
1
2
3
4
5
Least Important
Very Important
1 is Least Important, 5 is Very Important
What are your hair goals? Select all that apply...
Growing Hair Long
Getting Hair Healthy
Getting Color
Staying Trendy
New Look
Have you switched hair stylists more than 3x's in one year?
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