NBR® APPLICATION

1
What's your FIRST Name?* This field is required.
2
Nice to meet you, {fname}!

I'm Britney and I'm looking forward to taking a deeper dive into your hair goals and how we can achieve them!

I apprciate you taking the time to fill out my intake form. It will help me assess the current state of your hair, hair goals and to be best prepared for our consultation.
3
What is your last name?* This field is required.
4
What is your phone number?* This field is required.
Area Code
Phone Number
5
What is your email address?* This field is required.
example@example.com
6
What are your preferred pronouns:
ze/hir/hirs
they/them/theirs
he/him/his
she/her/hers
7
Are you currently wearing any form of hair replacement (crown +/ extensions, wig)?* This field is required.
YESNO
8
How long have been wearing hair replacement?* This field is required.
0-3 Months
4-12 Months
1-3 Years
4-6 Years
7-10 Years
10+ Years
9
Have you tried any form of hair replacement in the past?* This field is required.
YESNO
10
What hair replacement methods have you tried, and what has been your experience with them?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
11
Which of the following describes your hair texture?* This field is required.
Fine
Medium
Coarse
12
Which of the following describes your hair?* This field is required.
Very little amount of hair.
Medium amount of hair.
A lot of hair.
13
Do you colour your hair?* This field is required.
YESNO
14
Are you looking to change your hair colour completely, or stay with what you have today?* This field is required.
Radically change my colour
Stay with what I have, with minor adjustments
15
Show Me Your Current Hair

Follow the instructions below and upload photos of your current hair on the next steps.

This is the final stage of the application and the most important.

Must be photos of your current hair.

Use your cell phone.

Have someone else take the photo for you (No Selfies)

Take in natural lighting indoors (No Flashes or Direct Sunlight)

You will take two photos - Front and Back.
16
Upload your front shot:* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
17
Upload your back shot:* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
18
Hair inspiration pictures:* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
19
Please select the picture that best describes your hair loss:
Other
20
At what age did you first start to notice hair loss?
21
What area(s) did you first notice you were losing hair?
Front
Back
Temples
Crown
Hairline
22
Have you been to see your doctor or a trichologist regarding your hair loss?
YESNO
23
Have you sought your doctors permission to seek out hair replacement options?
YESNO
24
Have you had any previous hair loss treatments?
Yes, medication
Yes, laser
Yes, other
No
25
Is there a family history of Hair Loss?
YESNO
26
Are you looking to non-surgically restore your lost hair with a hair replacement system?
YESNO
27
Are you currently on any medications that would impact your hair?
YESNO
28
Do you have any medical conditions which may affect hair loss?
Alopecia
Lupus
Diabetes
Cancer or receiving Chemotherapy / Radiation Treatment
Hormonal / Thyroid Problems
Scalp Infection
Anaemia
Menopause
Stress
Other
None
29
Do you pull your own hair out/ Suffer with the condition called trichotillomania?
YESNO
30
Do you perspirate a lot?
YESNO
Should be Empty: