Consultation Form - Healthy Hair Coaching | Hair Loss Consulting

Healthy Hair Coaching | Hair Loss Consulting

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* Indicates required field

First Name *

Address *

Last Name *

City *

Email *

State *

Occupation *

Zip *

Home Phone *

Cell Phone *

1. How often do you visit a Salon? *

When was your last visit? *

What service did you receive? *

2. Have you ever had a curly perm (jherri curl)? *

Have you ever had a relaxer? *

Last relaxer service date? *

Has your hair ever been over processed or under processed from chemicals or hair color? *

If yes, when? *

3. Have you ever had a color service? *

If yes, when? *

What kind? *

4. Have you ever had your hair and scalp analyzed? *

If yes, was it recommended? *

What kind? *

5. Were you pleased with the results of the last chemical services? *

What kind of brand names? *

Salon or Barber name? *

6. What services do you usually require? *

Bleach Henna Relaxer Haircut Shampoo & Style Hair Extensions Scalp Treatments Other

How often do you shampoo your hair? *

7. Please list name brand products of hair products you are using at home:

Shampoo: *

Other Products *

Conditioner: *

Hair Spray: *

Scalp Oil *

Do you have a reaction to any type of hair products? *

If yes, please list the types *

8. Which styling implements do you uses? *

Brush Hot Comb Blow Dryer Hot Rollers Curling Iron/Flat Iron Hooded Dryer Other

Have you ever lost your hair due to braids, weaving or wigs? *

If yes, when? *

9. Are you taking any medications? *

Do you have any allergies? *

If yes, list medications: *

If yes, list allergies: *

Upload Photos *

Max file size: 20MB

Upload any photos of problem areas that you feel would be useful during our consultation

Upload Photos *

Max file size: 20MB

Signature: *

Upload Photos *

Max file size: 20MB

Upload Photos *

Max file size: 20MB

Date: *

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Home
Members Access
12 Week Growth Challenge
Private 1-on-1 Healthy Hair Coaching
Private 1-on-1 Hair Loss Coaching
In-Salon Services
About Kendra
Contact
Shop