Full Legal Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number *

(###)

###

####

Are you currently taking any medication? *

Health History

Yes

No

Check ALL that apply *

Health History

Smoke

Skin Cancer

Follow a Restricted Diet

Exercise Regularly

Swim

Use a Sauna

Do Water Aerobics

None Apply

Are you allergic to any of the following? *

Click all that apply

Latex

Bees

Nuts

Milk

Eggs

Soy

Wheat

None

What Challenges are you experiencing? *

Hair Health. Check all that apply

Dandriff

Dry/Itchy Scalp or Flaking

Receding Hairline

Growth Problems

Brittle or Dry Hair

Thinning

Soreness

None

How often do you receive a haircut or trim? *

Every 6 to 8 weeks

Every 6 months

Once a Year

Never

How often do you shampoo and condition your hair? *

Daily

1x / week

2x/ week

Every 2 weeks

Every 3 weeks

How often do you visit a Salon? *

Every 2 Weeks

Once a Month

Twice a Year

Once a Year

Never

Cancellation Policy *

CANCELLATION POLICY: My schedule is dedicated to my clients and their needs, but when I have a no-show or last minute cancellation I cannot fill that appointment with another person. As a result I require at least 48 hours notification. Please login to your account to cancel an appointment. For reasons other than emergencies, any cancellation under 48 hours would incur a fee of 25% of the total amount of booked services. SATURDAY same-day cancellation fee: 50% of scheduled service• No-call/no-show: 100% charged according to service

Release *

*RELEASE OF LIABILITY, WAIVER OF CLAIMS AND INDEMNITY AGREEMENT I have read and understood each section of this questionnaire prior to signing this document. I will follow all procedures to ensure my results are optimum. By signing this agreement, I acknowledge that I am aware that the results will vary from person to person. I cannot hold Cheeks: Makeup | Hair | Lashes; C & D Global, INC; or MS&N International, Incorporated or any of it’s subsidiaries legally or financially responsible for the pre-chemical condition of my hair, which will have an effect on my resulting style. I will call with any concerns within 24 hours of my service and I hold Cheeks: Makeup | Hair | Lashes ONLY responsible for resolving issues not related to my negligence promptly, free of charge and with full awareness of my hair’s chemical boundaries. I am fully aware of the cancellation policies and will adhere to them. I understand that the above information will be kept confidential and is accurate to the best of my knowledge.