Hair Donation Form
Donor's Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Email Address
example@example.com
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is the color of your hair?
Light Brown
Dark Brown
Blonde
Red
Black
Upload a photo of your hair (before)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload a photo of the cut hair (after)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
What are your reasons for donating your hair?
Date of Hair Cut
-
Month
-
Day
Year
Date
Name of the Salon
I confirm to the following:
I confirm that my hair was not treated chemically.
I confirm that my hair was not colored.
I confirm that I don't have a grey hair
I confirm that my hair is clean and dry
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Yes
No
How did you hear about us?
Facebook
Twitter
Instagram
YouTube
Online Advertisement
Google Search
Referred by a friend
Newspaper/Magazine
Other
By signing the form below, I confirm that all information in this form is true and accurate.
Signature
Clear
Date Signed
-
Month
-
Day
Year
Date
Print Form
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