New Client Consultation Form

Consultation Form

Required for all returning clients and to be filled and submitted prior to appointment.
Date

MonthDayYear
Date
Name

First NameLast Name
Program Overview

The 3 month treatment membership includes 1 scheduled treatment every 4 weeks for a total of 3 treatments during the membership term.
History
Are you taking any blood pressure medicine?
Have you had surgery in the last 2 years ?
If Yes, did they put you to sleep?
When did your surgery take place?

MonthDayYear
Date
Are you allergic to any food or have allergies?
Are you on any weight-loss pills?
Have You experience Dandruff or dry skin conditions? (Check all that apply)

Other
Is there anything that concerns you that we should address? Are you thinning or experiencing breakage? Please explain anything that you had to list for "other".
Would you be interested in a scalp analysis performed by our hair-loss specialist?
Membership Cost and Payment
Membership Incentives

Clients enrolled in 90-Day Treatment Plan will receive the following incentives:

Enjoy built-in treatments and incentives tailor-made to your hair-care needs. Incentives are non transferable and must be used during the membership period. This includes Tea Rinse, Aloe Treatment, Trim, Steam-treatment (or treatment that better serves your hair) A simple Flat-twist, wig-braids or crochet pattern. Feel free to add to the sevice for a separate charge for silkpress or cornrow service.
Membership total cost is $330
Scheduling, Rescheduling & Cancellations
Refunds & Termination
Client Responsibilities
Liability Waiver
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this service provider from liability and assume full responsibility thereof.
Agreement & Acknowledgement
By signing below, both parties agree to the terms and conditions of this 3-Month Treatment Membership Agreement.
Client Signature
Stylist Signature
Email
example@example.com
Should be Empty:

Consultation Form

Program Overview

History

Membership Cost and Payment