Name *

First Name

Last Name

Phone *

(###)

###

####

Have you visited HEIR before *

Yes

No

Have you had a skin test at HEIR before *

Yes

No

Do you suffer from a sensitive scalp/skin irritation? *

Oily scalp

Itchy scalp

Dandruff

Eczema/Psoriasis

Thinning hair

Sensitive Scalp

Other

My scalp is healthy

How would you describe your current hair colour? *

Very Light-I have a natural lighter base and/or past highlights.

Mid Tones-I have medium to light artificial coloured hair

Dark Base-I have had previous darker tints or vibrant artificial colour

How would you describe your percentage of white/grey hair? *

Use our white hair percentage guide below

Up to 25%

Up to 50%

Up to 75%

Up to 100%