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Client Information
We love our clients @Dare 2 Be Different Salon. In efforts to give you as much of my time in your appointment, This initial intake form will help us get to know you better to help provide you with the best hair care experience possible.
* Indicates required question
Email
*
Record my email address with my response
First and Last Name
*
Your answer
Address
Your answer
Phone number
*
Your answer
Date of birth
*
MM
/
DD
/
YYYY
Email Address
*
Your answer
where you referred by someone?
*
yes (if so please right name in other box )
No
Other:
Required
when was the last time you had any type of hair color(by yourself or professionally done)
*
4-8 weeks
8-12 weeks
4 months +
never, virgin hair
which of these describe your hair?
*
fine
curly
grey
kinky
thick
Required
how would you describe your hair condition?
*
oily
dry
combination
normal
Other:
Required
what service do you normally have done?
*
color
wash and go
extensions
none, first time at a salon
Other:
Required
Are you sensitive to, or have you suffered a reaction from any scalp related treatments or chemicals?
*
Yes
No
Other:
Do you suffer from any allergies?
*
Yes
No
Other:
What products do you currently use?
Your answer
Have you ever suffered from hair loss?
*
Yes
No
Other:
Have you ever been Diagnosed with alopecia?
*
Yes
No
Other:
Have you been pregnant in the last 6 Months?
*
Yes
No
Does not apply
Other:
Do you suffer from psoriasis to the scalp?
*
Yes
No
Other:
Do you have sensitive scalp?
*
Yes
No
Other:
Do you have suffer from eczema of the scalp?
*
Yes
No
Other:
Have you ever used hair extensions before?
*
Yes (please explain in the other box)
No
Other:
Required
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