Nanoplasty Client Consultation

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NANOPLASTY CONSULTATION FORM

TO ENABLE US TO GIVE YOU THE BEST RESULTS FOR YOUR NANOPLASTY SERVICE WE APPRECIATE YOU TAKING THE TIME TO TELL US A LITTLE ABOUT YOUR HAIR, YOUR AT HOME HAIR CARE ROUTINE & WHAT YOU'RE LOOKING T ACHIEVE USING NANOPLASTY.

Name *

First

Last

Mobile:

Are you currently pregnant or breastfeeding?

Yes
No

Do you have any allergies or medical issues we should be aware of?

Yes
No

List details of any allergies or medical issues:

Are you currently taking any medication:

Yes
No

Name Details &

If yes, please provide details:

About Your Hair:

Have you previously had a straightening treatment before? (Either here or at another salon)

Yes
No

If yes, how long ago & what type of treatment?

Please describe your scalp condition:

Dry
Oily
Normal
Other Scalp Issue

Recent Hair Treatments:

Have you had any of the following treatments recently? Indicate the date of last treatment.

Colour:

Yes
No

Date of last colour:

Bleach / Scalp Bleach:

Yes
No

Date of last bleach/scalp bleach:

Chemical Straightening:

Yes
No

Date of last chemical straightening:

Perm:

Yes
No

Date of last perm:

Brazilian Keratin Straightening:

Yes
No

Date of last Keratin Straightening:

Nanoplasty:

Yes
No

Date of last Nanoplasty:

Please describe the current condition of your hair:

How often do you wash your hair?: (eg Daily, every 2nd day, once a week etc)

Describe your natural hair texture: (eg fine, medium, coarse, curly, prone to frizz)

Describe your hair density: (fine, medium, heavy, dense etc)

Home Hair Care Products:

Please list the hair care products you are currently using at home (Brand / Type)

Shampoo:

Treatments:

Styling Products:

How do you normally style your hair at home?:

What do you like & dislike about your hair?

Please describe the Desired Look you want to achieve with Nanoplasty:

Is there anything else we should know about your hair or health that may effect this service?

Yes
No

If yes, Provide Details of what we should know:

Caroline Springs | Phone: 0488 77 00 33 | Email: info@mjsstyleroom.com.au