Name *

First Name

Last Name

Phone

(###)

###

####

Was there permanent color on your hair? *

Yes

No

Has your hair ever been box dyed or colored at home? *

(This includes SALLY'S)

Yes

No

Has your hair ever been colored red or black? *

Red

Black

Neither

Do you have grey hairs to cover? *

Yes

No

Do you, or have you ever put henna on your hair? *

Please answer this question honestly; if your hair was previously exposed to henna it could pose a risk for smoking or catching fire.

Yes

No

Is dandruff or flakiness an issue? *

Yes

No

Somewhat

My hair is... *

Can select multiple

Dry

Damaged from heat

Brittle (breaks easily)

Receding (receding hairline)

Damaged at the ends (split ends)

Frizzy

Limp

Thinning

Chemically over-processed

None of the above

How often do you apply heat? *

Never

Daily

Once in a while

2-3 times a week

How often do you prefer to style your hair? *

Air-dried and styled

Only blow-dried

Blow-dried and styled

Only air-dried

Do you have hair extensions? *

Yes

No

Do you have a natural curl/wave to your hair? *

Yes

No

Do you plan on wearing your hair curl? *

(50-100% of the time)

Yes

No

Have you ever had any type of chemical relaxer? *

(Brazilian blowout, GK smoothing, relaxer etc.)

Yes

No

Do you use purple shampoo? *

Yes

No

Do you have a hard water filter? *

Please note: It is highly recommended to purchase a hard water filter in the central coast area

Yes

No, I'm planning on getting one.

CANCELLATION POLICY: *

If we receive less than 72 hours notice you will be charged 50% of your service price. If less than 24 hour notice is given 100% of the service will be charged. If for some reason we cannot charge you, you will not be able to make an appointment with any stylist at Central Coast Hair Co until that fee is paid and 50% of your future service is paid upfront as well.

I agree to the cancellation policy.

Will you allow Central Coast Hair Co to use your photos in all web-based publications and promotion for Central Coast Platinum and the stylist's individual promotion? *

Yes

No

I want to subscribe to Central Coast Hair Co's Email List *

Yes

No