Client Intake Form

Client Intake Form
Full Name:

First NameLast Name
Date of Birth (Birthdays are important to me!)
This information is for your client profile. It will be used for special birthday promotions.
Email Address:
example@example.com
Phone Number:
Format: (000) 000-0000.
Preferred method of communication
Appointment Address
Health & Safety
Do you have any allergies, sensitivities, scalp conditions, or medical concerns that may affect your service?

Yes (please explain):
If you answered "Yes"please explain
Do you have any hair or scalp concerns?
List anything about your hair that may be relevant to your appointment.
Have you had any chemical services (color, highlights, perm, relaxer, keratin treatment, etc.) within the last 12 months?
Service Requested
Service Requested

Other
Preferred day and time for appointment
My normal hours are Monday 9:30am-4pm. If you're requesting outside of these hours, please list here.
Additional Information
Is there anything you'd like me to know about your hair, comfort, accessibility needs, or service goals?
Please list anything that you would like me to know about yourself (any limitations you may have or concerns)or your household( are there any pets, stairs ect.) that is relevant to your appointment.
Other information

These questions are optional. I use this information to see if you may qualify for special pricing. Everyone deserves access to essential haircare despite their ability to pay.
Are you receiving public assistance or on Medicare?
Do you avoid haircuts due to the cost of services or will it cause you financial hardship to receive this service?

Other
Have you ever served in the United States military, armed forces, or uniformed services?
Consent
I confirm that the information provided is accurate to the best of my knowledge. I understand that I am responsible for communicating any allergies, sensitivities, or health concerns prior to my service.
Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Client Intake Form

Health & Safety

Service Requested

Additional Information

Other information

Consent