Name
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First Name
Last Name
Email
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Phone
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Preferred contact method
Email
Phone
Text
Date of birth
What services are you interested in?
If you are interested in a package, select one below:
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Preferred Date
MM
DD
YYYY
How did you hear about me?
Instagram
Google
At an event
Referral
Other
Describe your typical daily routine, including work and exercise habits
On average, how many hours of sleep do you get each night?
How would you rate your stress levels?
Do you experience any of the following?
(Check all that apply):
Describe your current scalp condition:
Normal
Dry/Flaky
Oily
Sensitive
What are your primary concerns with your hair?
Thinning
Breakage
Dullness
Frizz
Do you experience any hair loss or shedding?
Yes
No
If yes, how long has this been occurring?
How often do you wash your hair?
Daily
Every other day
Once or twice a week
Other
If you selected other, please explain below
List any products you currently use on your hair and scalp:
How much water do you drink daily?
Do you consume electrolytes in your diet?
Yes
No
If yes, what source?
Have you ever experienced dehydration symptoms?
Check all that apply
Are there any other health or beauty concerns you’d like to address during your consultation?
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Please type your full name if you give content to your personal information being used for the purpose of my consultation. By typing out your full name, you understand that all information is kept confidential
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