Hairfinity - Healthy Hair Consultation

Full Name:

Email Address:

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Address

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Please indicate your hair type:

African American (Ethnic)
Caucasian
Asian
Other

Please indicate any of the following services you have had in the last year:

Chemical Relaxer
Sodium Hydroxide
Permanet Wave
Guanidine Hydroxide
Permanent
Semi-Permanent
Higlights / Bleach

Please indicate if you have had any of the following hair/scalp problems im the last year:

Breakage
Shedding
Dryness
Thinning
Dandruff
Scalp Itch
Ringworm/Fungus
Balding
Slow Growth

Check the ingredients of the shampoos you use and indicate if they contain any of the following:

Ammonium Laureth Sulfate
Ammonium Lauryl Sulfate
TEA Laureth Sulfate
TEA Lauryl Sulfate
Sodium Lauryl Sulfate

Do you heat style your hair?

Yes
No

Please indicate the conditioners/treatments you use often:

Please indicate any of the following that you do regularly:

Exercise
Drink Water
Take Vitamins
Smoke
Drink Alcoholic Beverages

Please indicate any other issues or concerns:

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Healthy Hair Consultation