Hair Talk Quiz Form

1

RevitalizeHER Holistic Hair Wellness Quiz?

2

What issues would you like to solve?* This field is required.

Hair

Scalp

All the above

3

Want to stop your hair from falling?* This field is required.

Yes

No

4

Want to grow thicker, fuller hair?* This field is required.

Yes

No

5

Want to stop your hair from balding and fill in bald spots?* This field is required.

Yes

No

6

Want to grow back your edges?* This field is required.

Yes

No

7

What is your #1 hair goal?* This field is required.

8

What type of hair problems do you have?* This field is required.This is a safe place to talk about your hair or weight trauma.

9

What are your biggest frustrations with your hair?* This field is required.

10

If you could wave a magic wand, how would you solve?* This field is required..

11

Want products to solve your hair issues?* This field is required.

Yes

No

12

Would you like to schedule an virtual hair wellness consultation? * This field is required.

13

First Name* This field is required.

14

Last Name* This field is required.

16

How did you find us?* This field is required.

Instagram

Tiktok

Youtube

Facebook

17

Mobile Number* This field is required.

Area Code

Phone Number

18

Email* This field is required.

example@example.com