Name *

First Name

Last Name

Text Number *

(###)

###

####

Preferred appointment time *

Morning/Early afternoon

Late afternoon/Evening

How would you describe your hair? *

Check all that apply*

Long

Medium

Short

Fine

Coarse

Thick

Thin

Straight

Curly

Wavy

Damaged

Healthy

Virgin

Have you done any of the following in the last 5 years? *

Check all that apply*

At home color/bleach

Perm

Fashion colors

Professional color

Professional highlights/balayage

Have you taken any of the following? *

Ozempic (generic included)

Accutane

None