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* 1. First and Last Name:

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* 2. Cell phone #:

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* 3. Is your scalp dry or oily?

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* 4. What is your hair type? (select all that apply)

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* 5. How often do you use heat on your hair?

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* 6. What are your hair goals?

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* 7. Describe your skin type

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* 8. Do you struggle with any of the following skincare concerns:

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* 9. Do you have any of these health concerns?

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* 10. Are you also interested in an of the following:

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