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This form is for guests who have not had a color service performed at Gervais before, guests who are making a significant change to their existing hair color, or who have not had color done here in over a year. This form will assist your stylist in formulating a plan for your color which is informed by your hair history as well as your aspirations.

Cancellation Policy:

We require 24hrs notice to change, rescedule or cancel an appointment. Out of respect and support for our Service Providers we will automatically charge the card on file.  Please give us a call if you have any questions.


 

First Guest Name

First Name*

Middle Name

Last Name*

Phone*
First Guest Date of Birth*
First Guest Information

What pronouns do you use?
Photo Consent: I grant Service Provider permission to reproduce, publish, distribute or otherwise use in any reasonable manner my name, photograph,likeness and statements, including, but not limited to, before and after pictures of my skin in connection with the promotion of the Service or the products used in the Service (or other similar services and products) in all media, including without limitation, the internet, news articles, advertisements, or other electronic or printed materials.*
No
Yes
First Guest Signature*
Second Guest Name

First Name*

Middle Name

Last Name*
Second Guest Date of Birth*
Second Guest Information

What pronouns do you use?
Photo Consent: I grant Service Provider permission to reproduce, publish, distribute or otherwise use in any reasonable manner my name, photograph,likeness and statements, including, but not limited to, before and after pictures of my skin in connection with the promotion of the Service or the products used in the Service (or other similar services and products) in all media, including without limitation, the internet, news articles, advertisements, or other electronic or printed materials.*
No
Yes
Third Guest Name

First Name*

Middle Name

Last Name*
Third Guest Date of Birth*
Third Guest Information

What pronouns do you use?
Photo Consent: I grant Service Provider permission to reproduce, publish, distribute or otherwise use in any reasonable manner my name, photograph,likeness and statements, including, but not limited to, before and after pictures of my skin in connection with the promotion of the Service or the products used in the Service (or other similar services and products) in all media, including without limitation, the internet, news articles, advertisements, or other electronic or printed materials.*
No
Yes
Fourth Guest Name

First Name*

Middle Name

Last Name*
Fourth Guest Date of Birth*
Fourth Guest Information

What pronouns do you use?
Photo Consent: I grant Service Provider permission to reproduce, publish, distribute or otherwise use in any reasonable manner my name, photograph,likeness and statements, including, but not limited to, before and after pictures of my skin in connection with the promotion of the Service or the products used in the Service (or other similar services and products) in all media, including without limitation, the internet, news articles, advertisements, or other electronic or printed materials.*
No
Yes
Fifth Guest Name

First Name*

Middle Name

Last Name*
Fifth Guest Date of Birth*
Fifth Guest Information

What pronouns do you use?
Photo Consent: I grant Service Provider permission to reproduce, publish, distribute or otherwise use in any reasonable manner my name, photograph,likeness and statements, including, but not limited to, before and after pictures of my skin in connection with the promotion of the Service or the products used in the Service (or other similar services and products) in all media, including without limitation, the internet, news articles, advertisements, or other electronic or printed materials.*
No
Yes
Sixth Guest Name

First Name*

Middle Name

Last Name*
Sixth Guest Date of Birth*
Sixth Guest Information

What pronouns do you use?
Photo Consent: I grant Service Provider permission to reproduce, publish, distribute or otherwise use in any reasonable manner my name, photograph,likeness and statements, including, but not limited to, before and after pictures of my skin in connection with the promotion of the Service or the products used in the Service (or other similar services and products) in all media, including without limitation, the internet, news articles, advertisements, or other electronic or printed materials.*
No
Yes
Seventh Guest Name

First Name*

Middle Name

Last Name*
Seventh Guest Date of Birth*
Seventh Guest Information

What pronouns do you use?
Photo Consent: I grant Service Provider permission to reproduce, publish, distribute or otherwise use in any reasonable manner my name, photograph,likeness and statements, including, but not limited to, before and after pictures of my skin in connection with the promotion of the Service or the products used in the Service (or other similar services and products) in all media, including without limitation, the internet, news articles, advertisements, or other electronic or printed materials.*
No
Yes
Eighth Guest Name

First Name*

Middle Name

Last Name*
Eighth Guest Date of Birth*
Eighth Guest Information

What pronouns do you use?
Photo Consent: I grant Service Provider permission to reproduce, publish, distribute or otherwise use in any reasonable manner my name, photograph,likeness and statements, including, but not limited to, before and after pictures of my skin in connection with the promotion of the Service or the products used in the Service (or other similar services and products) in all media, including without limitation, the internet, news articles, advertisements, or other electronic or printed materials.*
No
Yes
Ninth Guest Name

First Name*

Middle Name

Last Name*
Ninth Guest Date of Birth*
Ninth Guest Information

What pronouns do you use?
Photo Consent: I grant Service Provider permission to reproduce, publish, distribute or otherwise use in any reasonable manner my name, photograph,likeness and statements, including, but not limited to, before and after pictures of my skin in connection with the promotion of the Service or the products used in the Service (or other similar services and products) in all media, including without limitation, the internet, news articles, advertisements, or other electronic or printed materials.*
No
Yes
Tenth Guest Name

First Name*

Middle Name

Last Name*
Tenth Guest Date of Birth*
Tenth Guest Information

What pronouns do you use?
Photo Consent: I grant Service Provider permission to reproduce, publish, distribute or otherwise use in any reasonable manner my name, photograph,likeness and statements, including, but not limited to, before and after pictures of my skin in connection with the promotion of the Service or the products used in the Service (or other similar services and products) in all media, including without limitation, the internet, news articles, advertisements, or other electronic or printed materials.*
No
Yes
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Most Recent Color History
Have you had color done within 1 year?*
No
Yes

What was the approximate date of your last color?
Type of previous color*
Professional (Salon)
At-Home/DIY
None
Hair History
How would you describe your natural hair color?*
Very pale blonde
Medium blonde
Dark blonde/Light brown
Strawberry Blonde/Red
Dark Red/Auburn
Medium brown
Dark brown
Black
Grey (partially or fully)
White
Check what chemical processes you have done to your hair in the last two years: *
Highlights or Balayage
All-Over Color
Permanent Straightening
Temporary Straightening
Perm
Relaxer
Henna
None of the above
Check any pertinent hair issues you have experienced in the last year
Hair breakage/brittle hair
Hair loss
Unusually dry hair
Your Hair Color Goals
What kind of color are you interested in receiving at Gervais?
Highlights
Balayage
All-Over Color
New Growth/Grey Coverage
Bright/Fashion color
Semi-Permanent Gloss
Your Hair Color Goals cont.
  
Please provide inspiration photo here *
Valid file types: JPG, GIF, PNG, and PDF
Additional inspiration photos
  
Please provide inspiration photo here
Valid file types: JPG, GIF, PNG, and PDF
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

What pronouns do you use?
Photo Consent: I grant Service Provider permission to reproduce, publish, distribute or otherwise use in any reasonable manner my name, photograph,likeness and statements, including, but not limited to, before and after pictures of my skin in connection with the promotion of the Service or the products used in the Service (or other similar services and products) in all media, including without limitation, the internet, news articles, advertisements, or other electronic or printed materials.*
No
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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