Hairgrowth Consultation and Information Form

Phone Number

Area CodePhone Number

Name*

First NameLast Name

Email*

example@example.com

Are you experiencing hairloss or shedding?

	Yes	No
Click yes or no

Is your scalp dry or oily?*

DryOilyComboNormal

Is your scalp itchy or flaky?*

ItchyFlakyNeither

Do you have sensitive skin or a sensitive scalp?*

How often do you wash your hair?*

Is your hair texture*

FineCoarseIn between

How dense is your hair?*

ThinMediumDense

Is your hair:*

StraightWavyCurly

Is it frizzy?*

YesNo

Which do you need more of?*

MoistureGrowth

Is your hair damaged?*

YesNo

Is your hair colored or lightened?*

ColoredLightened

Have you had any chemical processes done, other than color? (If so, please list). *

How do you dry your hair?*

Blow dryAir dryBoth

Do you use a curler or straightener?*

YesNo

Do you have any allergies? (If so, please list them.)*

What do you currently use for hair products? (Brand and type.)*

Would you like more information on how you could make money by using these products and sharing them?*

Yes pleaseNo thank youIn the future

Best time to contact