About You


Name:
Email:
Cell:
Work:
When do you want to come in:
Address:
City:
State:

Zip:
Occupation:
Date of Birth:

How did you hear about us:

Health

Meds:
Yes No
If Yes, What type:


Birth Control:
Yes No

Allergies:
None Food Meds Color Other
If Other Specify:


Pregnant:


Any other health concerns:

Scalp

Eczema:
Yes No
Psoriasis:
Yes No
Seborrheic:
Yes No
Missing hair on scalp:
Yes No
If Yes, Where:

Have you been seen by a Dermatologist/Trichologist:

If Yes, When:


Hair



Who usually cares for your hair:


Do you frequently visit a salon?
Yes No
If Yes, Where:
Last visit:

Last relaxer service:

Brand and Strength:


Last color service:

Brand:


Last cut/trim received:

Shampoo/Cond currently using: