Mesh Integration Form
Consultation Form
Name
*
Address
*
Contact Number
*
DOB
*
Before Picture?
*
NO
YES
Is Your Scalp.
*
Oily
Dry
Normal
How Often Do You Wash?
*
Every day
Every other day
Every 3-4 days
Once a week
Discussed and supplied aftercare?
*
Yes
No
Is a GP note required?
*
YES
NO
Do you have any cuts or legions on your scalp that could become irritated?
*
YES
NO
Do you have any MRI scans due ( Integration system would need to be removed for this)?
*
YES
NO
Do you have Psoriasis ( Dry scalp, build up of skin)?
*
YES
NO
GP Details.......
*
Medical History? (Cancer are not suitable please seek doctors or insurers advice)
*
How long have you suffered from this medical condition? (If you have a medical condition)
Recommended treatment...
Chosen quality, thickness, colour and length of system?
*
Date Of Consultation
Date Of Fitting
General Overall Cost (If known)
Nickel Allergy? (if servere client may not be suitable as as rings contain nickel)
*
Deposit Paid?
*
Next Appointment
Clients Signature
*
Extensionist Signature
I certify that I am over the age of 18 and that I am not under the influence of drugs or alcohol. I certify that I have received a full consultation and that the mesh integration/crown volumiser treatment has been fully explained to me inc aftercare and advise I wish to receive.
*
I CONFIRM I DO NOT HAVE A NICKEL ALLERGY (SEEK DOCTORS ADVISE IF NECCESARY ) OR ANY ALLERGIES THAT MAY AFFECT THE SYSTEM. I CONFIRM I HAVE HAD MY AFTERCARE TO WHICH I STRICTLY ADHERE. I VERIFY THAT MEDICAL AND PERSONAL INFORMATION I HAVE GIVEN IS ACCURATE AND I KNOW NO REASON WHY I WOULD NOT BE SUITABLE FOR THIS TREATMENT. I FULLY UNDERSTAND THAT MY PRACTIONER IS REQUIRED TO TAKE AND STORE PHOTOS OF MY HAIR AND I CONSENT TO THIS BEING DONE. I UNDERSTAND THAT MAINTENANCE IS TO BE COMPLETED EVERY 6 WEEKS AND REALIGNMENT EACH 6 MONTHS . I HAVE READ AND FULLY UNDERSTAND ALL OF THE ABOVE AND THEREFORE, THE REQUIREMENTS HAVE BEEN EXPLAINED TO ME FULLY AND I CONSENT TO THE MESH SYSTEM?CROWN REPLACEMENT TREATMENT.
*
I am fully aware Extensions/Mesh Systems are high maintenance and I have to follow the aftercare advised to me and attend regular maintenance. I fully understand if I do not care for the system correctly I can cause damage to my natural hair. I take responsibility for the aftercare and maintenance of the system fitted and I have answered this form correctly. Any changes due to personal preference of the system will be charged extra. I have read all of the above and consent. Please sign below
*
I understand if a new a medical condition occurs whilst wearing the system, crown volumiser, this may risk increasing hair loss, also I understand that my hair may be too weak for the system/volumiser and I understand attending all the required appointment is very important. I have disclosed all of the information to the best of my knowledge and will update my practitioner immediately should I notice any change in medical condition and hair as this is my responsibility. Please sign below
*
Back
Next
Submit
Should be Empty: