Midori Eco Salon New Client Intake Form
To perform Hair Color Treatment procedure in a safe manner, please answer the following health questions truthfully. We will keep all information disclosed in a confidential manner and will use it only for purposes of determining whether you are an ideal candidate for this procedure.

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Name (First, Last) *
Date of Birth *
MM
/
DD
/
YYYY
Phone Number *
Address  *
Email  *
Opt-In for email list to receive information and offers? *
How Did You Hear About Us? *

Please briefly describe the reason for today's consultation:
 *
Please describe your hair and scalp condition by checking all that apply: *
Required
What products and treatments do you use at home? Please check all that apply *
1 X Weekly
2 x Weekly
3 (or more) x Weekly
Shampoo
Conditioner
Leave - In Conditioner
Heat Protectant
Hair Mask(s)
Hair Serum/Oil
Please list the brand of hair products you are using at home. *
How do you style your hair (Blow-Dry, Iron Curl, etc)? *
How much time do you spend maintaining your hair? *
Do you have any allergies to certain products or ingredients? If so please explain. *
Please rate your current daily stress level (please select one). *
Do you color your hair at home? *
Please identify any services you are interested in (Check all that apply: *
Required
By selected the box below, you are agreeing to the following:

I have completed this form to the best of my ability and knowledge. I agree to inform the technician of any changes to the information listed on this client intake form. I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liabilities toward the technician and Midori Eco Salon for any injury or damages incurred due to my misrepresentation of my health history.
 *
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