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Hair Extension Form
To help us better understand your needs, please answer the following questions
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First Name
Your answer
Last Name
Your answer
Street Address
Your answer
City
Your answer
State
Your answer
Zip
Your answer
Phone
Your answer
Why do you want hair extensions? Please be specific
Your answer
Are you wanting a more temporary solution, or something that will last as long as possible?
Something that will last as long as possible
Temporary solution
Clear selection
How long do you want your hair to be? What is your long-term goal for your hair?
Your answer
Have you worn extensions before?
Yes
No
Clear selection
If yes: What type were they?
Your answer
When were they installed?
MM
/
DD
/
YYYY
How long did you wear them?
Your answer
Was it a good experience?
Yes
No
Clear selection
Have you ever experienced excessive hair loss or damage to your natural hair due to extension installation service? If so, please elaborate.
Your answer
Describe your normal hair Maintenance routine:
How often do you wash your hair?
Daily
Every Other Day
2 Times a Week
Once a Week
Hardly ever
Clear selection
What products do you use on your hair?
Your answer
Do you blow dry your hair often or style it with heat tools?
Your answer
How often do you cut your hair?
Your answer
Do you color, perm or straighten your hair? If yes, how often?
Your answer
What chemical procedures have been performed to your hair the last three year
Perm
Hilighting/Balayage/Lightening Process
Smoothing Treatment
Clear selection
Health
Are you currently taking any medications, or under any physicians care? If yes please list all medications or explain your situation
Your answer
Have you been ill, undergone surgery, or given birth in the last six months? If yes, please explain
Your answer
Do you have any allergies?
Yes
No
Clear selection
Do You have a sensitive scalp?
Yes
No
Clear selection
Are you currently experiencing an unusual amount of hair loss? If yes do you know why?
Your answer
Lifestyle
Do you sunbathe, use a tanning bed or utilize sunless tanning sprays or lotions?
Yes
No
Clear selection
What are your special interest, hobbies and exercise routine?
Your answer
How often do you like to change your hairstyle or color?
Your answer
How often do you like to change your hairstyle or color?
Your answer
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