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New Client Contact Form

Please fill out the form below to be added to our customer list.

First & Last Name:

Phone:

Address:

Email:

What is your haircare goal?

What haircare products are currently used?

Do you suffer with Alopecia, thinning, dandruff, itching, etc?

Do you eat at least 5 servings of fruit, veggies, protein, grains daily?

Do you drink at least 8-10 glasses of water daily.

Do you exercise at least 3-5 times a week?

Do you take vitamins or herbal supplements?

List allergies to any essential oils

List any current medications. How long?

How do you handle stress?

Are you interested in trying Holistic Healing therapies? *Reiki, *Reflexology, *Massage, *Meditation, *Prayer, *Visualization, *Yoga

How did you hear about us?

Any comments?

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