Hair Loss Consultation Form
Let us know how we can help you!
Full Name
First Name
Last Name
Birth date
-
Month
-
Day
Year
Date
Age
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Help us understand you better.
Natural Hair Color
Natural Gray %
How long have you had hair loss?
Have you had treatment and did you get any success with the treatment, if yes, how?
Is Your Scalp Hurt/Tender/Inflamed?
Any Health Issue? If Yes, What Issues?
Dandruff?
Yes
No
Is Your Scalp Itchy or Flaky?
Yes
No
Do You Have Thyroid, Anemia Issues?
Thyroid
Anemia
None
Are you under a physician's care?
Yes
No
Any Diet Restrictions?
Any Recent Surgery? If Yes, What Type?
Any allergies?
Are You Currently Dieting In The Past 6 Months, Any Dramatic Weight Changes?
Your weight?
Below
Normal
Slightly Obese
Obese
Do You Take Any Vitamins, If Yes, What Type?
Have You Changed or Stopped Taking Medication Recently? If Yes, What Medication/s?
Did you give birth in the last 18 months?
Yes
No
Hot Flashes?
Yes
No
Do You Over Process Your Hair? Use Hot Hair Dryer, Colour, Hair Straightener? Perm? Relaxers?
Do You Tie Your Hair Pony Tail, Braiding, Extensions?
How Often Do You Wash Your Hair?
Please Provide Any Additional Information About Your Hair And Scalp Condition That Is Useful For Our Assessment
How did you find me?
Referral
Website
Social Media
Other
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