“How Healthy is Your Hair & Scalp?”
Congratulations on taking the next step to achieving the hair and scalp you've been desiring. Please allow yourself a few minutes to answer the questions listed below. Also, please be sure to answer all question as honestly and accurately as possible. In doing so will better help me understand your hairs current condition and what steps are needed to help you achieve your goals as well as finding the proper solution to accommodate you. Once completed, I will review your submission and give my professional feedback. This will be your first step to a new and healthy haircare regiment that best fits your needs!
I am currently...
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Natural (chemical free)
Transitioning (some chemical)
Relaxed
Color Treated
Are you currently seeing a professional hair & scalp specialist?
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Yes
No
Are you experiencing issues or discomfort of the scalp?
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Yes
No
If you answered yes to the previous question, what scalp issues and/or discomfort are you experiencing? How long have you been experiencing these issue? How are you treating this issue?
Are you experiencing hair loss of any kind? (ex. thinning, balding, alopecia, etc..)
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Yes
No
If you answered yes to the previous question, how long have you been experienced hair loss? How are you treating your hair regarding this matter?
Are you interested in products that would help solve your hair and/or scalp issues?
Yes
No
My current hair care regiment consists of the following...
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Products used on my hair and scalp consist of the following...
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If I could change anything about my hair & scalp I would change...
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Would you like help achieving these goals?
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Yes
No
If you answered yes to the previous question please select the best date and time to call. (Please keep in mind callbacks will be done on Mondays, between 10-6 EST.)
Date
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Month
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Day
Year
Date
Time
Hour Minutes
AM
PM
AM/PM Option
Full Name:
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First Name
Last Name
Phone Number
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Please enter a valid phone number.
Email
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example@example.com
Instagram Handle
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Submit Your Quiz Here
Should be Empty: