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  • New Client Consultation Form

    Billco, Owner Hair Replacment Specialist/Master Barber/Instructor
    New Client Consultation Form
  • Consultation Type:*
  • Format: (000) 000-0000.
  • In case of emergency
  • Format: (000) 000-0000.
  • Have you ever been treated for any hair and/or scalp problems?*
  • Have you had prior hair transplants?*
  • What activities or hobbies do you participate in regularly? (Check all that apply)*
  • Please indicate which areas of life your hair loss have affected you. (Check all that apply)*
  • What is your main goal? (Check all that apply)*
  • Are you in good health?*
  • Are you presently under a doctors care?*
  • Taking any medications, currently?*
  • Have you ever had any type of bleeding disorders?*
  • Do cuts on your skin heal normally?*
  • Do you have a tendency to keloid?*
  • Have you ever required additional anesthesia at the dentist?*
  • Have you ever had an allergic reaction to anesthesia?*
  • Have you had any allergic responses or adverse reactions to substances put onto your skin?*
  • Do you take large amounts of aspirin?*
  • Have you had any allergic responses or adverse reactions to any drugs or medications?*
  • Are you financially able at this time to do something about your hair loss?*
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    Consultation Product Image
    Consultation

    Once you have made your payment, completed this form and submitted it; we will then schedule your consultation appointment. During your consultation, you will be able to ask all the questions you have and based on the results from your consultation, we will then discuss the hair replacement system that will be the best fit for you. When you have made your decision on the unit and the direction in which you would like to go, an invoice is then submitted to be paid prior to booking an appointment, the $100 consultation fee is credited to that invoice. Once the invoice is paid, you can then receive your Game Changing appointment.

    $109.90
      
    Total
    $0.00

    Credit Card
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  • By signing this, I acknowledge that all the information I have provided in this form is accurate and true to the best of my knowledge.

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