Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Birthday

MM

DD

YYYY

What would you like to get out of your salon experience?

Check all that apply

I want a new look

Just routine maintenance

I want to learn to work with the hair that I have

I want to learn to use styling tools

I want to relax in silence

Have you used any of these chemical services in the past two years?

Texturizer

Relaxer

Permanent Color

Semi/Demi Permanent Color

Keratin Treatment

Other

Current hair condition:

Heat Damaged

Frizz

Itchy Scalp

Dandruff

Alopecia

Breakage

Oily

Dry

Healthy

Where was your hair colored?

At home

A professional salon

Do you have any allergies to hair colors or products?

Yes

No

Not that I know of

What is your budget for maintenance?

I'm ok with a bigger budget for the first appointment, but would like something with less maintenance

Budget is not a problem to maintain the color

What is the most important for you to experience at the salon?

Check all that apply

I'd like to learn about products and styling my hair

I'd like to see a significant change in my hair

I'd like to learn about other services you provide in the salon

I'd like to have a quiet appointment and relax while getting my hair done

I'd like my hair to stay in great condition, with limited damage