CARTER BARNES BEAUTY BOOST APPLICATION
| Name
| Age
| Phone Number (cell, if available)
| Address
| E-mail address*
| Upload Photo
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Photo
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Please use one line to describe the current condition of your hair:
| Has your hair been chemically treated?
| If yes what chemical treatments have you received?
| What is the date of your last chemical treatment?
| What is the date of your last haircut?
| Which services would you like to receive?
| If you currently receive a color treatment, please mark ONE of the following:
| Please use one line to describe the changes you want done to your hair (i.e., "I want to be a redhead, I want to be a blonde, I want to maintain my current color, I want my hair cut short," etc.).
| Please use 100 words or less to describe your current lifestyle situation (i.e., job loss, income reduction, impacted by recent floods, etc.).
| Have you received Botox before?
| If yes, what is the date of last time you received Botox?
| Would you be interested in receiving Botox?
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