Picky Pam at the Beach
NOTE: Dreadlocks, hair extensions, and/or extremely coarse hair, open sores and/or extremely severe (over 1,000 estimated nits) might not be suitable for our products and treatment. Our treatment requires a child to sit on their own for a minimum of 1 hour.
Thank you!
Adult/Parent's (FIRST) Name *
Adult/Parent's (LAST) Name *
Cell Number
Email Address *
School
How did you hear about us
Child's Name 1 *
Child's Age 1 *
Child's 1 Gender
Clear selection
Does Child's 1 have access to cell phone/tablet
Clear selection
Treatment (For Office Use Only)
Child's Name 2
Child's Age 2
Child's 2 Gender
Clear selection
Does Child 2 have access to cell phone/tablet
Clear selection
Treatment (For Office Use Only)
Child's Name 3
Child's Age 3
Child's 3 Gender
Clear selection
Does Child 3 have access to cell phone/tablet
Clear selection
Treatment (For Office Use Only)
Child's Name 4
Child's Age 4
Child's 4 Gender
Clear selection
Does Child 4 have access to cell phone/tablet
Clear selection
Treatment (For Office Use Only)
Product (For Office Use Only)
Adult Treatment (For Office Use Only)
You are done. Hand tablet back to Picky Pam Staff for them to begin head check. Please DO NOT HIT SUBMIT
Captionless Image
Captionless Image
Captionless Image
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy