Confidential Questionnaire

Name *

First Name

Last Name

Date *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone *

(###)

###

####

Work Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Referred By *

TV Ad

Internet

Yellow Pages

Radio

Salon (Enter below)

Other (Enter below)

Are you allergic to shellfish? *

Yes

No

Describe the condition of your scalp. Check all that apply. *

Itchy

Oily

Dry and Flaky

No scalp conditions

What type of cleansers are used? *

Sulfate Free

Dandruff cleansers

Other (Describe below)