Your Hair Story Schedule an Appointment by Calling (617) 547-8098 1General Info2Health Info3Hair History I am a...(Required) First-time Client Returning Client Requesting a virtual consultation via Zoom Name(Required) First Last Email(Required) Phone(Required)Birthdate MM slash DD slash YYYY How did you hear about Simply Erinn's? Facebook Instagram Other Website Yelp Person who referred you: First Last Your HealthMedicationsList any and all medicationsYour ScalpDo you have scalp concerns? Eczema Flakes Hair Loss/Baldness or Thinning Psoriasis Seborrheic Dermatitis Soreness If you have any scalp concerns, what parts of your scalp are affected Frontal Hairline Frontal Scalp Parietal Scalp Temporal Recession Temporal Scalp Vertex Have you been seen by a Dermatologist/Trichologist?YesNoWhen were you seen? MM slash DD slash YYYY Name of Dermatologist/Trichologist First Last If there was a diagnosis please explain:Are you using prescribed medication?YesNoName of medication prescribed? Current Natural remedies? Your Hair HistoryWho mostly cares for your hair? You Salon Other Most recent salon visitMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Most recent trim/cutMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Most recent color serviceMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Most recent chemical serviceSuch as a perm, relaxer, or keratin treatmentMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Brand and strength of chemical treatment? How often do you use a hot tool?(blow dryer, curling iron, curling wand, flat iron, etc.)DailyWeeklyMonthlyYearlyRarelyNeverPictures of your current products and hair will help us make your consultation as productive and helpful as possible.Current Hair ProductsPlease line up all your hair products horizontally and take a picture. Drop files here or Select files Accepted file types: jpg, png, gif, Max. file size: 10 MB. Current Hair Pictures(Required)Please take the pictures zoomed out to understand your facial features, texture and head shape. Upload the necessary pictures below: Multi pic uploader: Front, Both sides, and Back picture. Drop files here or Select files Accepted file types: jpg, png, gif, Max. file size: 20 MB. Optional: Video upload (3 minutes or less)Directions: hair up and down for front,side and back of head shots, center of head, and any close ups of problem areas, finish with a full 360 headshotAccepted file types: mp4, Max. file size: 20 MB.NameThis field is for validation purposes and should be left unchanged. Client Cancellation Policy Read Our Policies
