• Confidential Consultation Questionnaire

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  • History

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  • Medications: Please list name of medication and dosage

  • We never give Minoxidil, Complete, AA, MGT, etc. or anything to pregnant, trying to get pregnant or nursing mothers other than shampoo and conditioner.

  • How many daily servings of protein do you eat?

  • Trichology Hair Service Release Waiver Form

  • Angel's Eyes of Beauty from any pre-existing hair loss problems as it relates to my hair loss and scalp disorders consultation. I further release Angel's Eyes of Beauty from any lawsuits or claims that come as it relates to any services that I may receive. Angel's Eyes of Beauty practitioners have my permission to receive any information necessary from my previous stylist and medical professional either to myself or to whoever provides the free consultation service for purpose of clinical research.

    I authorize information directly to 101 HLAWR of care listed above. I understand that hair growth is based on each individual’s hair loss and wellness needs. I give permission for documentation and photographs of any pre-existing problems to be taken and used by Angel's Eyes of Beauty. I agree that photographs and photographic copies of this statement shall be valid.

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  • Disclaimer: The purpose of this consultation is for Angel's Eyes of Beauty to gain knowledge by using our Medical Image and utilizing the Medical Questionnaire form. We may provide precautionary measures to possibly prevent the progression of hair loss and re-grow hair for the client. However, the Practitioners of Angel's Eyes of Beauty (hereafter referred to as Angel's Eyes of Beauty) assume absolutely no liabilities for any injuries resulting from the consultation or any other information provided by the Practitioner. Clients knowingly and willfully assume all such risks and responsibilities upon themselves and hold harmless Angel's Eyes of Beauty and any parties associated with Angel's Eyes of Beauty with respect to any and all hair care and health issues, whether arising from the negligence of Angel's Eyes of Beauty or otherwise.

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