Name *

First Name

Last Name

Phone

(###)

###

####

Have you ever colored your hair?

No

Yes

Are there any box dyes, henna, or other at-home treatments in your hair history? *

Box Dye

Henna

Other

None

Have you had any chemical treatments (keratin, relaxer, perms, etc.) in the last two years? *

No

Yes

Do you have concerns about damage or breakage? *

No

Yes

Are you comfortable having pictures or video taken of your hair during your appointment? *

No

Yes