Hair Restoration Pre-Consult Form

Hair Restoration Pre-Consult Form

Welcome to DeLuco's Hair Spa! I can’t wait to help you begin restoring your hair health. Please take a moment to fill out the following questions so that I have all the information needed to create the right therapy program and recommend the proper haircare products that are just right for you. All new guests start working here with a digital consultation form. I’ll be in touch within 24 hours of your request during my work week which is Monday through Friday. All requests submitted Saturday-Sunday will be responded to on Monday. If you have any questions or need support, please email me at delucoshairspa@gmail.com.
What is your full name?*

First Name Last Name
What is your email address? *
Please note, I will be reaching out by email to confirm your appointment
Phone Number*
Please note, I will respond by text to confirm your appointment
May I leave personal messages on this phone number?*

YesNo
What is your mailing address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
How did you hear about me?*
Tell us more about how you found us*
What is the name of the client who referred you to my business?
Age
Occupation
Please list all known allergies*
Do you have a shellfish allergy?*

YesNoNot Sure
Have you had any recent surgeries or been given anethesia?*

YesNo
How would you describe your daily stress level?*

LowMediumHigh
Please check all that apply to you:*

StrokeIrregular heartbeat/ Congestive heart failureDepressionEndocrine disorderHigh blood pressureAnemiaThyroid conditions/PCOSDiabetesSkin Conditions/ EczemaMenopauseAnxiety/ High stressLiver diseaseRapid weight gain/lossRecent loss of a loved oneLupusNone of the aboveOther
Please list all prescribed medications you are currently taking?*
Are you experiencing any menopausal symptoms?*

YesNo
Family History: Check anyone in your family that has experienced hair loss*

FatherMotherGrandparentAunt/UncleSiblingNo known family history
At what age did you start to notice your hair loss?*
What brand of shampoo/ conditioner do you use currently?*
How many times per week do you shampoo?*
What have you tried to help with your hair loss so far?*

TransplantsOver the counter productsPrescription productsHair loss clinicMinoxidilHaven't tried anything yet
Do you eat animal protein?*

YesNo
How many cups of caffeine do you drink in a day? ( soda, sports drinks, coffee or tea)*
How is your sugar intake?*

HighMediumLow
Do you eat a lot of processed foods?*

HighMediumLow
Do you smoke cigarettes?*

YesNo
Is your scalp:*

Dry or flakingOilyNormal
Have you experienced dandruff or itchy scalp recently?*

YesNo
Have you experienced any attacks of patchy large areas of hair loss?*

YesNoNot sure
Commitment to the program is essential in the results you receive. Are you willing to stay committed and wait at least 6 months to see results with our program we create for you?*

YesNo
Is there anything else we should know before booking your appointment?*
I am being evaluated at DeLuco's Hair Spa and understand that I will first undergo a comprehensive preliminary evaluation by a hair loss practitioner, Michelle DeLuco. This evaluation will determine if I am a suitable candidate and I understand that the cost of the initial evaluation is $50 consultation fee which will be applied towards a laser therapy program chosen. I further understand that although XTC products and laser light therapy has had many successful results, each client is different and like any cosmetic treatment, results will vary depending on many factors. I acknowledge that it is my responsibility to inform Michelle DeLuco of any changes in my health condition no matter how minor.
Signature*
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