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Home - Hair and Scalp
Services
Hair Styling
Haircuts and Trims
Relaxers
Trichology and Scalp Therapy
Color
Hair Extensions
About
Contact
Customer Reviews
Shop
Financing
Care Credit Financing
Cherry Payment Plan
Good Vibez Beauty
Body and Hair by Jonna
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EMAIL
Confidential Questionnaire
Name
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First Name
Last Name
Date
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Address
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Address 1
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Home Phone
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Work Phone
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Date of Birth
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Age
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Email
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Referred By
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TV Ad
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Salon
Other
Personal History
Allergies
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Are you allergic to shellfish?
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Yes
No
General Health
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Please list any and all health concerns, conditions and/or disorders.
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Please list any and all medications, vitamins, and supplements that you have been taking, and for how long.
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Describe the condition of your scalp. Check all that apply.
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Itchy
Oily
Dry and Flaky
No scalp conditions
Other
What chemical services have you received in the past?
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Describe your current hair condition.
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How often is your hair cleansed?
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What type of cleansers are used?
*
Sulfate Free
Dandruff cleansers
Other (Describe below)