BHS General Hair Consultation Form

  • This consultation should take approximately 10 minutes to complete. Please answer all questions accurately to the best of your knowledge. All information obtained will be kept private and confidential.

  • Hair Assessment Form

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  • Would you like to receive SMS notifications? (standard data rates may apply)*
  • Please enter your birth date:*
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  • What service are you interested in?
    • Health History & Lifestyle 
    • Your hair is a reflection of your health and it is very important that we have an accurate picture of your lifestyle in order to recommend appropriate services and products for you.
    • How much water do you drink daily (on average)?*
    • Do you have allergies or adverse reactions to any of the following? (select all that apply)*

    • What does your diet mostly consist of?*
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    • How often do you exercise?*
    • Are you currently taking any medications ?*
    • Hair & Scalp History 
    • How would you describe the health of your hair?*
    • How would you describe your scalp?*
    • On average, how often do you shampoo your hair?*

    • Do you currently cover your hair at night?*
    • Do you have any scalp issues?*
    • Are you currently experiencing any of the following:*
    • Have you ever been treated by a physician for hair loss or scalp issues? *
    • Please specify what area(s) are experiencing hair loss:*

    • Was the hair loss sudden or gradual? *
    • Is the hair loss getting worse? *
    • Rows
    • What bothers you most about your hair loss? *

    • What are you goals / expectations regarding your hair loss?*
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    • Product & Regimen Overview 
    • How often do you apply a WATER-based moisturizer?*
    • How often do you oil your hair / scalp?*
    • A photo/video may be taken during your appointment. Are you okay with having photo/video including your face posted online (website, social media, etc.)?*
    • PHOTO / VIDEO CONSENT AND RELEASE Effective as of the date of submission, approval for past use and permission for present and future use is being granted to Jocelyn Bryant of NuGrowth Salon, to use a picture or voice recording of {name3}. Permission is being given by the undersigned, {name3}, of {address} (the "Recorded Party"), as more fully explained in this Consent and Release. The undersigned is an adult and fully authorized to sign this Consent and Release.   For a valuable consideration, receipt of which is hereby acknowledged, the undersigned hereby grants to Jocelyn Bryant its agents, employees, licensees, and successors in interest (collectively, the "Released Party") all ownership rights and the absolute and irrevocable right and permission to copyright, use and publish the recorded image and/or voice of {name3} (the "Image and/or Voice") that has been (or is being) obtained pursuant to this Consent and Release.   The Image and/or Voice may be copyrighted, used and/or published individually or in conjunction with other photography, video works, and recordings, and in any medium (including without limitation, print publications, public broadcast, CD-ROM format) and for any lawful purpose, including without limitation, trade, exhibition, illustration, promotion, publicity, advertising and electronic publication.   The undersigned represents and warrants that (i) no other party has been granted an exclusive license with respect to the Image and/or Voice, and (ii) no other party's authorization or consent is required with respect to the permission granted to the Released Party under this Consent and Release.   The undersigned waives any right that the undersigned may have to inspect or approve the Released Party's use of the Image and/or Voice, or the advertising copy or printed matter that may be used in connection with the use and/or publication of the Image and/or Voice. The undersigned releases the Released Party (and all persons acting under its permission or authority) from all claims for libel, slander, invasion of privacy, infringement of copyright or right of publicity, or any other claim related to the Image and/or Voice (collectively, "Claims"). This release includes without limitation any Claims related to blurring, distortion, alteration, optical illusion, digital alteration, use in composite form, whether intentional or otherwise, or use of a fictitious name, that may occur or be produced in the processing or publication of the Image and/or Voice.   THE UNDERSIGNED WARRANTS THAT THE UNDERSIGNED HAS READ THIS CONSENT AND RELEASE PRIOR TO THE SIGNING OF THIS DOCUMENT, THAT THE UNDERSIGNED UNDERSTANDS IT, AND THAT THE UNDERSIGNED FREELY ENTERS INTO THIS CONSENT AND RELEASE.
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