Today's Date
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Month
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Day
Year
Date
What's your name?
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First Name
Last Name
Phone Number
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-
Area Code
Phone Number
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Stylist:
Relaxed or Natural?
*
Relaxed
Natural
Last time and type of relaxer
Do you have a permanent color or rinse in your hair?:
Yes or No
Date of Last Color Service:
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Month
/
Day
Year
Date
Are you currently taking any medication?
*
Yes or No
Do you have any history of hair loss or scalp conditions?
*
Any hair issues that you are concerned about?
*
How did you hear about us?
*
If you were a referral from one of our client's, please provide their name:
Please provide the names of the products you're currently using:
Thank you!! Please let us know if there is anything we can do to make your experience the best!
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