CLIENT INTAKE FORM

Personal Profile:

Name: __________________________________________ Date:____________________________

Address:___________________________________ Contact No.:_____________________________

Gender:__________________________________________ Age:_______________________________

CLIENT CONSULTATION
Reason for Visit or Consultation:___________________________________________________________

 Have you had a chemical relaxing or straightening treatment in the last year? Yes___No____

Date of Application:_________________

 Have you had hair color or highlighting/hair bleaching application in the last year? Yes___ No___
Date of Application:____________________

 Do you use heating tools to style at home? Yes____No_____ How often?_______

Blow dryer_____ Hair Flat Iron_____Steamer_________ Others_________________

 Do you have any product allergies?______________

 Do you have dandruff, flakes or dry itchy scalp?__________________

 In the past 6 months (currently) have you been treated by a doctor or dermatologist of any of
the following?

Dandruff______ Alopecia___________ Ringworm____________Others____________

 Do you presently have any breakage, thinning areas or bald spots? If yes, where?___________

 What hair products are you currently using?______________________

 Do you have any questions or concerns?____________________________________________

 HAIR ANALYSIS

Porosity Over Porous Normal Porosity Non-Porous

Elasticity Elastic Non-Elastic
Texture Smooth Course
Amount Thin Average Thick
Length Short Long

Hair Condition: ___ Virgin Hair ___ Damaged Hair ___Chemically Treated Hair

Wave Pattern: ___ Straight ___Wavy ____Curly Hair ___Kinky Hair

Operator’s Recommendations:

___________________________________________________________________________________

___________________________________________________________________________________

After Care Advices:

____________________________________________________________________________________

____________________________________________________________________________________

Agreement:

I fully understand and agree all the terms stated above.

________________________________
Client’s Name and Signature

__________________________

Operator’s Name and Signature