Turn Your Hair Disaster Into a Dream Makeover — Apply Now for Blotched! Name * First Name Last Name Email * Phone * (###) ### #### Date of Birth MM DD YYYY Message * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Preferred contact method * Phone Email Text Describe what went wrong with your hair. (Tell us exactly what happened — whether it was done at a salon, by yourself, or due to another circumstance.) * When did this happen? MM DD YYYY Have you tried to fix it before? If so, how? * Yes No How have you tried to fix it? What services are you hoping for? * Color correction Hair Extensions Both color correction and extensions Other (Please specify) Other Tell us your story * How has your hair situation impacted your confidence or day-to-day life? * Why do you think you’d be a great fit for Blotched? * Do you currently have any hair loss or thinning? * Yes No If yes, please explain Have you experienced hair loss due to a medical condition or treatment? (e.g., alopecia, chemotherapy, hormonal changes) * Yes No Do you have any allergies or sensitivities to hair color or products? * Yes No If so, which colors or products? Have you ever worn extensions before? * Yes No Thank you!
