New Client Info/Consultation Form

New Client Info/Consultation Form

CLIENT INFORMATION
Name

First NameLast Name
Gender
Ethnicity
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Occupation:
Do you have children?
If yes, please list ages:
HAIR INFORMATION

Honesty to the best of your ability!
Are you experiencing Hair Thinning or Hair Loss?
How long have you been losing your hair?
Is there a family history of Hair Thinning or Hair Loss?
Naturally, how long is your hair?
List areas of hair loss or breakage:
temple/edgescrown areaback of napeothern/a
What types of Relaxers do you wear?
How often do you Relax your hair?
Salon Visits
How often do you visit the salon?
How often do you shampoo and condition your hair
Please list type of shampoos and conditioners used:
Please read below and check all that apply:
When was your hair last trimmed?
Are you interested in hair training (Defining your curly texture)
Have you ever worn Color?
Have you ever worn Hair Extensions?
If yes, please list what type?
Hair and Scalp
Had a hair transplant?
Have you ever visited a Dermatologist?
If yes, please give outcome of the visit?
Is your scalp:
How would you rate your hair’s condition
*The information provided will be kept confidential and will be used exclusively for the purpose of providing proper hair care treatments and solutions.
Should be Empty:

HAIR INFORMATION