Holistic Trichology NG Intake Form

Holistic Trichology Consultation

Are you struggling with hair loss and or scalp conditions? We will get to the root of the problem and then provide treatment solutions to provide solutions that work.

You will need the following blood tests completed before a consultation will be scheduled.
1. Complete Blood Count w/Differential (CBD)
2. Thyroid panel
3. Comprehensive Metabolic Panel (CMP)
4. Antinuclear Antibody (ANA) Only if you suspect or have any autoimmune issues
5. A1C Only if you have or suspect you have diabetes or are pre-diabetic.
Need your blood work updated? Click here to schedule your tests

Any Labs Now - Blood tests available

I am not a medical doctor or able to diagnose medical conditions. However, with my holistic trichology training, I can determine areas in your body out of balance through blood tests, completing this form, and scalp analysis.

This form is for non-salon services only. If you are additionally considering extensions or color services, please complete the new guest questionnaire: https://form.jotform.com/212148877066160. Salon services and trichology consultations are not combined.
This document contains sensitive information and is of considerate length. Please take your time answering these questions, as it will help me give you the best solution and care plan possible.
Please select one*

FemaleMaleTransgenderOther
Name*

First NameLast Name
Birthday (00-00-0000)*
E-mail*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mobile Phone*

Area CodePhone Number
How did you hear about me?*
What hair and or scalp conditions are you experiencing (select all that apply)

Hair loss (all types)DandruffInflammation of the scalpSeborrheic dermatitisFolliculitisPsoriasisTrichotillomaniaOther
Work Environment*

OutsideInsideDirtyCleanPaint, Chemicals, etc.Hot, Humid, etc.Other
Marital Status (select all that apply)*

SingleMarriedSeparatedDivorcedWidow/WidowerOther
# of dependant children (ages) *
if none type NA
When did you first notice you were losing hair?*
What did you notice at that time?*

hair "coming out" or sheddinghair looked thinner on scalpOther
Have you recently noticed that your hair loss was worsening?*

YesNo
If yes, when did you begin to notice it was worsening? *
What makes you think it was worsening? **
Current Daily Hair Loss*

30-50 strands50-80 strands80 strands & upUnsure

Please mark the box that best describes your family member's scalp hair. If you have more than one brother or sister, mark the box that describes the brother or sister who has the LEAST amount of hair

	has a lot of hair	has some thinning	has a small bald area	has a large bald area	has (or had) many bald spots	NA
Father
Mother
Brother
Sister

Have you been pregnant at any time before or during the hair loss *

yesno
When did the pregnancy end?*
Have you had a serious illness at any time before or during the hair loss?*

YesNo
Date of last physical exam *
If you know your blood type please enter here

Within the last six months, have you undergone treatment for any of the followingconditions?*

	Yes	No
Heart Trouble
Hypertension (high blood pressure)
Low Blood Pressure
Thyroid Imbalance
Pituitary Imbalance
Blood Disorder
Seizure Disorder (epilepsy)
Anemia
Diabetes
Keloid (scar formations)
Psoriasis
Skin or Scalp disorder
Body Building Steroids

Other medical treatments list here

Do you now, or have you: *

	Yes	No
Worn a hairpiece
Had hair transplants
had implants or fusions
Been on a diet
Lost or gained more than 15lbs (last year)
been eating a well balanced diet
been taking daily vitamins or supplements
had allergies
had allergies to drugs or medicine
had a recent accident
had recent surgery
had your scalp injured
been under a physician's care
been using drugs or medication
had excessive emotional strain
been in good health

Please describe the illness and when it occurred*
Please list the names of all the medications you are currently taking, include over the counter.*
Please list any medications that you WERE taking when your hair began to fall outthat you are NO LONGER taking.
Please list any vitamins or natural products that you are taking
What therapies (if any) have you tried for this problem?*
What do you usually eat for Breakfast (cook at home, eat out) *
What do you usually eat for Lunch (cook at home, eat out) *
What do you usually eat for Dinner (cook at home, eat out) *
What do you usually eat for snacks *
Frequency of exercise and activities
What are your top concerns or priorities for our consultation?*
Upload a photo of yourself showing your hair when it was normal*

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Would you rather drop off your blood work or upload it in this form?

MailUpload nowEmail separately
You can mail your blood work forms to:

Tabitha Osman

Charlotte Hair Studio

165 S Trade Street Suite 115

Matthews, NC 28104

You will receive directions via email or text to book your consultation after receiving blood work.
You can email your blood work forms to:

tabitha@charlottehair.com

Subject: blood test forms (and list your name)

You will receive directions via email or text to book your consultation after receiving blood work.

Please do not send screen-shots as important parts can be missed.
Complete Blood Count w/Differential (CBD) (no screen-shots please)

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Thyroid Panel

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Comprehensive Metabolic Panel (CMP) (no screen-shots please)

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Antinuclear Antibody (ANA) - Only if you suspect or have any autoimmune issues

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A1C - Only if you have or suspect you have diabetes or are pre-diabetic.

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Optional - Any additional blood tests you may have will add more insight into the report.

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Please review the following studio policies. By signing below you agree to the receipt and acknowledgment of these policies.

How to Reach Me

All text messages and calls are for appointment day arrivals only. All other communications regarding appointment changes or questions are to be sent to my email only at tabitha@charlottehair.com. Messages will be replied to during studio hours and within 24 hours.

Consultation Deposit

As there are costs associated with providing the blood analysis a $100 retainer will be paid before booking your consultation. The remaining amount due will be paid after your consultation.

Cancelation Policy

Due to the high demand on my time, I have to require a credit card to secure all consultations. Credit cards are stored securely and encrypted through my trusted booking software. Please give the courtesy of 48 hours' notice for any changes or cancelations. For no-shows and no calls, it is 100% of your consultation. Thank you for understanding.

Product Returns

I guarantee every product I sell in my studio. During our treatments, I will strive to educate you on how much, how often, and how to apply each product. If you find that the product is not performing the way you expected, feel free to bring it back and I will swap it out for another product, or I am happy to show you how to use the product again. I am unable to issue refunds for any products and we will not be able to use them after they have been opened.
Signature*

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