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* 1. Name, Phone Number & Email

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* 2. Is your scalp oily or dry?

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* 3. What is your hair type? (Select all that apply)

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* 4. How often do you wash your hair?

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* 5. How often do you use heat?

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* 6. What are your hair goals? (Select all that apply)

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* 7. Do you have any of these scalp concerns? (Select all that apply)

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* 8. Describe your skin type

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* 9. Do you struggle with any of the following skin concerns? (Select all that apply)

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

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