Hair Stylist Intake

Licensed Hair Stylist On-Site
Professional hair services are available on-site with a licensed hair stylist.

Location: Riverview Health Centre – One Morley Avenue
Booking Hours: Monday, Tuesday, Friday, Saturday 10:00 a.m. – 4:00 p.m.

Please complete the form below prior to booking an appointment with the stylist.

Hair Stylist Intake

"*" indicates required fields

Name

This field is for validation purposes and should be left unchanged.

Resident/Patient Name*

First Last

Community

(Please choose…)AB1AB2CD1CD2CD3CD42 East3 East4 East2 West3 West4 West

Name of Person Making the Request*

First Last

Relationship*

(Please choose…)Resident/PatientFamily MemberRepresentative/POA

Email*

Contact phone*

Home

Cell

Other

Home*

Cell*

Other*

Please indicate the hair salon service(s) you are requesting

Haircut

Colour

Temporary colour

Hair conditioning treatment

Pemanent wave and cut

Wash

Wash and blow dry

Wash and cut

Wash and roller set

Wash, cut and set

How often do you want this service?

Once

Weekly

Monthly

Other

Details of request

Payment method

*Cash & Debit Card / Credit Card is to be paid directly to the salon.

Trust account (Residents Only) *trust accounts must be up to date prior to booking salon services.

Cash

Debit Card / Credit Card

Signature

Date

MM slash DD slash YYYY