Name

First NameLast Name

Age

Date of Birth

Date

Phone Number

Please enter a valid phone number.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Hair Salon Technician Name

First NameLast Name

What is the length of your hair?

What is the color of your hair?

What is the current condition of your scalp?

Pre-procedure questions

	Yes	No	Remarks
Have you had hair extension before?
Do you have a medical condition wherein hair loss is present like alopecia?
Are you currently in treatment for hair loss?
Are you currently taking medication for hair loss?
Do you have any skin-related disease?
Are you sensitive to metals?
Do you regularly swim?
Are you currently on a GLP1 ?

Please upload an image of your current hair

Please upload an image of the hair that you want or your inspiration

I confirm that all information I entered in this form is accurate and true.
I understand that I need follow pre-procedure and post-procedure care.
I understand that for cancelation or rescheduling, I need to call the salon or clinic directly and talk to the staff to get voice confirmation.
I confirm that the clinic does not provide a refund for deposit payments.
I released the salon for any liabilities or hold harmless for any damages, injury, or accidents that can happen during or after the procedure.
I understand that removal must be performed by a hair salon technician or extensionist.
I understand that I must use salon quality products on my extensions.

By signing below, you agreed that you have read and understood the terms and agreement above.

Signature

Date Signed

Date

Hair Extension Consultation Form

Customer Information