Virtual Hair Consultation REG Form

Virtual Consultation Appointment Form

www.nouritress.com
NouriTress Virtual Hair Consultation offers a convenient solution for those seeking expert hair care advice. Through this service, individuals can connect with a Board Certified Licensed Cosmetologist, Certified Trichologist and Hair Loss Specialist for personalized assistance right from their homes. Using a smartphone, tablet, or computer, customers can engage in a video call to discuss their hair care concerns.

During this 30 minute private consultation, participants have the opportunity to speak directly with NouriTress CEO, Dr. DeShawn Bullard. This allows them to highlight specific issues with their hair, facilitating the development of a targeted treatment strategy. Recommendations may include using specific NouriTress Products or, if necessary, advice to consult a medical professional for further intervention.
Full Name*

First NameLast Name
E-mail*
Contact Number*

Area CodePhone Number
Age*
Gender*

FemaleMaleOther
Occupation*
How would you like to speak with a Hair Loss Specialist*

Video
Please select consultation reason

Hair ThinningHair LossAlopeciaCCCA (Central Centrifugal Cicatricial Alopecia)Other
Select all that apply

Thinning/Hair Loss in Crown AreaThinning/Hair Loss around the EdgesHair Shedding/BreakageVisit Hair Salon OftenWear Hair Extensions/WeaveWear WigsHair is NaturalHair is RelaxedVisited a DermatologistOn Prescription MedicationsStressWear Hair ColorWear BraidsOther
Appointment*
Upload A Photo of the Hair Area of Concern

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My Products

Virtual Online Hair Consultation$75.00

15-20 minute virtual consultation

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Virtual Consultation Appointment Form

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