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Hair Relaxer Intake Questionnaire
Please answer these questions as best as you can. Once we review your information, we will be in touch with you. Thank you.
* Indicates required question
Email
*
Your email
First Name
*
Your answer
Last Name
*
Your answer
What is the best phone number to reach you? (Include Area Code)
*
Your answer
Your Street Address?
Your answer
Your City
Your answer
Your State
Your answer
Your Zip Code
Your answer
Have you been diagnosed with any of the following conditions
*
Ovarian Cancer
Fibroids / Fibroid Tumors
Uterine Cancer
Hysterectomy
Other
Other:
Required
Age of first use of relaxer?
*
Your answer
Product name(s)
*
Your answer
Duration of use (how long did you use relaxer)?
*
Your answer
Frequency of use (how often did you use relaxer)?
*
Your answer
Preferred contact method
*
Phone
Email
Required
Is there anything else you would like to share with us?
Your answer
A copy of your responses will be emailed to the address you provided.
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