Last Name

Best Contact Number

E Mail Address

What is your basic hair color?

Black
Brunette
Redhead
Blonde
Gray
No Hair

How would you change your color with extensions?

No Change
Some Highlights
Some Lowlights
Fun Color Pieces Added

Which hair ethnicity best describes your hair texture? (not necessarily your lineage)

Caucasian (i.e. white )
Asian
Ethnic (i.e. black)
Other
No Hair

What is your basic hair density?

Thick
Average
Thin
Other
No Hair

How would you change your hair density with extensions?

No Change
Add a little thickness
Add a lot of thickness

What is your basic curl pattern?

Straight
Wavy
Curly
Kinky
Relaxed Straight
No Hair

How would you change your curl pattern with extensions?

No Change
More Body
More Curls

How long is your own hair?

No Hair
Crew Cut
To The Ears
To The Shoulders
To Mid Back/Bra Strap
To The Waist
Longer

How long do you want your hair to be?

To The Ears
To The Shoulders
To Mid Back/Bra Strap
To The Waist
Longer

Please check any of the following reasons for wanting this service

need length
need volume
need texture
need color
need highlights or low lights
special occasion
corrective purposes

Please explain answer.

List all medical conditions.

List all medications you take that can cause hair loss.

List all allergies & sensitivies.

Please check any of the following that apply.

alopecia sufferer?
unusual hair loss?
Was a doctor consulted about hair loss?
childbirth within 6 months?
chemo within 6 months?
do you use sulphur water to wash your hair?
do you have hormonal issues?
Do you swim a lot?
Do you have a latex allergy or sensitivities?
Does your insurance cover cranial prosthesis?
Do you have a metal allergy or sensitivities?
Do you have an adhesive allergy or sensitivities?
None of these apply

Please list all products & methods you have used in the past for hair loss, replacement & extensions

Is there anything you feel you need to tell us that is pertinent before obtaining these services?

Will you let us use your image for marketing purposes?

Yes
No
Modified (face blurred)

I have read & will comply with all directions on the hair extensions caresheet & Hair By Denise Policy.

Yes
No

Electronic Signature ( Please type your name ) for online estimate