Name *

First Name

Last Name

Phone *

(###)

###

####

Hair Condition *

Check all that may apply.

Dry

Heat Damaged

Over Processed/Chemically Damaged

Oily

Generally Healthy

Could be better

Have you had Box color in the last 3 years? *

Yes

No

Hair Density *

Fine/Thin

Average

Thick

Extra Thick

Do you have an grays?

Yes, but I am embracing them

Yes, I want them gone

No, thank goodness!

How often do you shampoo?

Once per Week

2-3 Times per Week - ish

Every day

Do you typically blow dry or air dry?

Mostly Air Dry

Mostly Blow Dry

Little bit of both