AI Scalp Consult Request
Screening & intake for semi-permanent scalp pigment density at Grow Hair Lounge
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about us?
*
Please Select
Instagram
TikTok
Google
Referred by a client
Already a salon client
Other
Hair & Scalp Details
What is your natural hair color?
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Black or very dark brown
Medium brown
Light brown
Blonde (medium to dark)
Light blonde, platinum, white, or gray
Which treatment areas are you concerned about?
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Crown/top of head
Hairline
Temples
Part line
Overall density/full scalp
Post-transplant density
Not sure
Tell us about your hair concern in your own words. What are you experiencing? How long has it been going on? What have you tried?
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Scalp Photos (Required Angles)
Crown view — phone directly overhead pointing down
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Upload a File
Drag and drop files here
Choose a file
Cancel
of
Front hairline — eye level straight on, hair pulled back
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Part line — camera above along natural part
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Left temple and side — head turned right, camera at eye level
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Right temple and side — head turned left, camera at eye level
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Optional: Upload up to 3 additional photos (optional)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Photo Release Consent
*
I consent to my photos being used for educational or marketing purposes
I do NOT consent to my photos being used
Health Screening (Check all that apply)
Pregnant or breastfeeding
Currently undergoing or within 6 months of chemotherapy or radiation
Active scalp condition (infection, psoriasis, eczema, etc.)
History of keloid scarring
Uncontrolled diabetes
Bleeding disorder or blood thinners
Autoimmune or immune-compromising condition (including immunosuppressant medications)
Accutane within past 6 months
Hair transplant within past 12 months
None of the above
Investment Acknowledgment: Packages start at $1,100 and go up to $3,000. A $100 consult fee is collected today and applied toward your package.
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Yes, I am ready to invest in my hair
I would like to discuss payment options
This is outside my budget right now
Consult Fee Payment
*
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Consult Fee
Non-refundable $100 consultation fee (applied toward package if eligible)
$100.00
$
100.00
Preferred Contact Method
Phone call
Text/SMS
Email
Any final notes or questions?
Submit Consult Request
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