Form
What is your age range
18 - 25
26 - 35
36 - 45
46 - 60
60 +
How long have you been experiencing hair loss?
Less than 6 months
6 - 12 months
1 -2 years
2+ years
What type of hair loss are you experiencing? (select all that apply)
Thinning
Receeding hairline
Patchy spots
Shedding
Have you received a professional diagnosis for hair loss?
Yes, (please specify type of hair loss if known in additional box below)
No, but I suspect a specific condition
No, I haven't been diagnosed
Do you have any of the following health conditions? (Select all that apply)
Thyroid Imbalance (hypo/hyperthyroidism)
Hormonal imbalances
Scalp conditions (seborrheic dermatitis, psoriasis, eczema, etc.)
Lupus or autoimmune conditions
Stress or anxiety
Diet related issue (low iron, vitamin deficiencies, etc.)
Other
Do you currently take medication for hair loss or scalp health?
Yes
No
Have you tried any hair loss treatments in the past? (select all that apply)
Topicals (minoxidil, etc)
Professional scalp treatments (micro needling, low-level laser therapy, etc)
Supplements (biotin, hair vitamins, etc)
Natural therapies (essential oils, herbal treatments, etc)
None of the above
What type of scalp care regimen do you currently follow?
Regular shampoo & conditioner
I use specialized scalp treatments
I follow a holistic approach (oils, herbs, etc.)
I don't have a consistent scalp regimen
Do you prefer a holistic approach (using natural products like essential oils, herbs, etc) or a clinical approach (including treatments like PRP or micro needling)
Holistic
Clinical
A combination of both
Are you interested in receiving personalized product recommendations for your hair and scalp care?
Yes
No
Would you be interested in a group coaching setting for ongoing support with your regrowth journey?
Yes, I'm interested
No, I prefer individual support
Would you prefer to be apart of a private group where you could watch videos, get tips on products and scalp health, and receive advice from guest scalp specialist for a monthly fee?
Yes, I'm iterested in a private group setting
No, I prefer a one to one approach
Would like more information
Would you like to schedule a consultation to discuss a personalized hair regrowth plan?
Yes, I'd love to schedule an appointment
I'd like more information before scheduling
Not at this time
Please share any additional concerns or goals you would like to address in your regrowth journey.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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