Client Inquiry Form for Hair Loss Extension Services at Juney Bee's Total Care

Client Inquiry Form for Hair Loss Extension Services at Juney Bee's Total Care

Please fill out this detailed form to help us understand your hair condition and personal preferences. Your information will assist us in providing personalized and effective care.
Full Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
State of Residence*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
How did you hear about our service?*
Have you previously used hair extensions?*

YesNo
If yes, what methods have you used before?
Reasons for stopping previous hair extension treatments (if applicable)
Type of hair loss you are experiencing*
Are you using any adhesives or bonding agents for hair extensions?*

YesNo
Do you have scalp sensitivity or allergies?*

YesNo
Main areas of hair loss*
Do you have any of the following conditions?

AlopeciaAllergiesCancerPsoriasisOther
Current symptoms related to hair loss or scalp condition
Are you currently experiencing menopause?

YesNo
Are you using any medications related to hair loss or scalp health?

YesNo
If yes, please specify the medications
Are you allergic to adhesives or similar bonding agents?*

YesNo
Do you agree to share your results and photos for promotional purposes?*

Yes, I agreeNo, I prefer to keep my results private
Upload Photos of Your Hair from Different Angles (front, side, back)*

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File Upload

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File Upload

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I agree to the terms and conditions, including payment responsibility and use of adhesives if needed.*

I agree to the terms and conditions.I acknowledge that I am responsible for payment.I consent to the use of adhesives in my treatment.
Would you like to schedule a consultation to secure an appointment ?*

Yes, I want a consultationNo, I just want information
Preferred scheduling timeline for consultation?
Please specify your preferred date and time for consultation (if any)
Consultation Payment

Consultations are available Monday to Wednesday from 9 AM to 1 PM.

My Products

Phone ConsultationConsultation via phone call.

$50.00

Virtual ConsultationConsultation via virtual meeting.

$150.00

September-Exclusive Alopecia Awareness New Client Extension ExperienceSecure this limited-time offer in September; valid through December 31. Open to new clients only with limited availability. Service includes extension installation up to 14 inches. Please arrive shampooed with a clean crown and at least 4 inches of hair in the back. A complimentary consultation is included. After purchase, our team will reach out to schedule your consultation online or by phone.

$950.00 Quantity

Product Name

$ Free Quantity

Total

$0.00

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Client Inquiry Form for Hair Loss Extension Services at Juney Bee's Total Care

Consultation Payment

Credit Card