Healthy Hair Quiz

1
Name:
First Name
Last Name
2
Best Way to Contact You:
Email
Phone Call
Text
Facebook/Instagram Messenger
3
Email Address:
example@example.com
4
Phone Number (optional):
Please enter a valid phone number.
5
Instagram Handle (optional):
6
How would you describe your natural hair type?
Straight
Wavy
Curly
Coily
7
How would you describe your hair texture?
Fine
Medium
Coarse
8
How would you describe your hair density? (how much hair is on your head)
Low
Medium
High
9
How would you describe the length of your hair?
Pixie
Short
Medium
Long
Very Long
10
How would you describe your overall hair quality? Check all that apply.
Thinning
Lacks Volume
Dry
Frizzy
Damaged
Dyed/Colored
Bleach Processed
Mostly Healthy
11
How would you describe your root/scalp quality?
Dry
Oily
Balanced
Flaky/Dandruff
12
How would you describe the ends of your hair?
Dry
Brittle/Breaking
Split
Mostly Healthy
13
How do you most often style your hair? (check all that apply)
Air Dry
Blow Dry/Diffuse
Heat Styling (Straightener/Curling Iron)
14
What is your main hair concern right now? Please feel free to share anything else you'd like me to know about your hair!
15
We offer intensive hair loss treatment hair plans. Low laser therapy is part of this plan. 6 month plans are $1689.00 and financing is available. Are you wanting to start on the treatment plans?
16
My Products
prevnext( X )
My Bag
0
My Bag
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
ORDER SUMMARY
Total costUSD
Book my 30 Minute Virtual Hair Loss ConsultationThis is a hair loss consultation where I ask questions about family history, medical history and about the history of your hair to come up with a treatment plan. Plans will vary depending on consultation. This consultation helps me go in depth with treatment plan and help to identify the type of hair loss you may be experiencing.
$50.00Edit
Back
Total cost $0.00
Credit Card
First Name
Last Name
17
AppointmentWhat day would you like your virtual consultation? Please make sure that you have included your phone number on this form.
18
What else would you like more information about?
Growth Products
Beauty Bootcamp
Hair Loss Classes
Business Classes
Hair Care Plan
Hair Loss Maintenance
19
Tags
Todo
In Progress
Done
Should be Empty: