Please enable JavaScript in your browser to complete this form.Date (DD/MM/YYYY)Name *FirstLastEmail *Contact Number *Patch TestPositiveNegativePreferred Appointment Date & TimeHobbies/Time OutdoorsPersonal Style/ Styling AbilitiesHair Desires (in 6-12 months)Hair Managability Selected Value: 01 - Extremely Difficult to 10 - Extremely EasyHair Likes & ChallengesCurrent Hair RegimeScalp Condition Selected Value: 01 - Poor to 5 - OutstandingScalp ConditionsAtpoic Dermatitis (Eczema)Contact Dermatitis (allergic rxn)Seborrheic DermatitisPsoriasisDry ScalpOily ScalpPityriasis (scaly, pink, inflamed skin)Tinea (Ringworm)ScabiesLiceFolliculitis (bacterial infection of follicle)Furuncle (Boil)Carbuncle (2+ Boils)ScarringHair Condition Selected Value: 01 - Poor to 5 - OutstandingHair ConditionsCanities (Greys)Hypertrichosis (Ex. hair growth)Alopecia (Hair loss)Heat DamageChemical DamageTrichoptilosis (Split Ends)Trichorrhexis Nodosa (Nodules along hair shaft)Fragilitas Crinium (Breakage)DrynessMonilethrix (Beaded Hair)Growth PatternCowlick (Grows stright out from head))Whorl (Circular area of hair growth)Widow's Peak ("V" at front hairline)Double Crown (2 whorls at top of head)Duck Tail (hairline at nape tpaers to "V")Hue (Pure Colour)Natural Level Selected Value: 01-Black, 2-Natural Black, 3-Darkest Brown, 4-Dark Brown, 5-Medium Brown, 6-Light Brown, 7-Dark Blonde, 8-Medium Blonde, 9-Light Blonde, 10-Extra Light Blonde, 11-Extra Light Blonde+Grey Hair (%) Selected Value: 0Underlying Pigment Selected Value: 01-Dark Red Brown, 2-Red Brown, 3-Dark Red, 4-Red, 5-Red Orange, 6-Dark Orange, 7-Orange, 8-Dark Yellow, 9-Yellow, 10-Pale Yellow, 11-Palest Yellow.Desired Level (1-11)Desired Tone.0 - Natural.1 - Ash.2 - Violet.3 - Gold/Warm.4 - Copper.5 - Brown.6 - Red.7 - Jade.8 - Mocha.9 - PearlHair Texture (Diameter)FineMediumCoarseHair Porosity (Absorption)LowMediumHighHair Patterns1 - Straight/Minimal Wave2 - Open Wave3 - Wavy4 - Curly5 - Very Curly6 - Coily7 - Very Coily8 - Zig Zag CoilDensity (Scalp Visibilty)LowMediumHighElasticity (Stretch Wet Hair)HighMediumLowHair Pull (Determine Shedding/Hair Loss)PositiveNegative1, Grasp 20 to 60 hairs between thumb, index and middle fingers, holding as close to the base of scalp as possible. 2. Tug on the hairs using a small amount of force. 3. If more than 10 % of the hairs grasped can be pulled out from scalp, it’s generally viewed as a sign that you’re actively shedding hair.Previous ChemicalsSemi-Permanent ColourDemi-Permanent ColourPermanent ColourPre-LightenedHenna-BasedMetalic BasedPermRelaxer - NaOHRelaxer - ThioKeratinSkinFairLightMediumMedium DarkDarkDeepUndertone (Veins)Warm (Green/Olive)Neutral (Blue-Green)Cool (Blue/Purple)Eye ColourAmber (Gold + Copper)BlueBrownGreyGreenHazel (Brown + Green)Face ShapeOvalRoundSquareTriangualrDiamondOblongProfileConvexConcaveStraightOther Notes/Suggestions. Submit