Name First Name Last Name Date MM DD YYYY Email Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Do you suffer from eczema on your head? Yes No Are you suffering from alopecia? Yes No Are you on any medication or suffering from an illness that causes hair loss? Yes No Do you suffer from psoriasis on your head? Yes No Do you bleach your hair? Yes No Have you had hair extensions before? Yes No Do you have a sensitive scalp? Yes No Are you allergic to any metals? Yes No Are you pregnant or have you recently given birth? Yes No Length of client's hair: Clients hair is: Straight Dry Wavy Greasy Curly Thin Medium Thick Length and type of hair client desires: Thickness client requires: Colour of client's hair: Colour of client desires: Elasticity test: Wet hair, Stretch, bounce back. Final Notes: Thank you!
