Hair Restoration Program Form

Hair Restoration Pre-Consult Form

Welcome to Root Revival! I'm so excited 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 rootrevivalrestore@gmail.com.
What is your full name?*

First NameLast 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

CityState / Province

Postal / Zip Code
How did you hear about me?*
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 let me know a little of your daily stress? Work, personal, health concerns, family, etc? *
Do you pull your hair or struggle with trichotillomania?*
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
Have you been diagnosed with any kind of cancer or received chemo treatments?*

YesNo
Are you experiencing hair loss on any other parts of your body besides the top of your head?*

YesNo
Please list all prescribed medications and vitamins you are currently taking?*
Please describe a standard day of eating? Breakfast, lunch, dinner, snacks, drinks?*
Do you drink coffee or soda? How much do you drink each day?*
How much water do you drink each day?*
Do you exercise regularly? If so how often do you exercise per week? *
Have you recently had any diet changes?*

YesNo
Are you perimenopausal or menopausal? Experiencing any irregularity in periods?*

YesNo
Are you pregnant or trying to conceive? Or have you recently just gave birth?*

PregnantTrying to conceiveJust had a babyNot at this time
Are you currently taking birth control pills or hormone medication?*

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

FatherMotherGrandparentAunt/UncleSiblingNo known family history
When did you start to notice your hair loss?*
Have you had Covid?*

YesNo
Did you notice any hair loss during or after?*
If you received the Covid vaccine, did you experience any complications after?*
What brand of shampoo/ conditioner do you use currently?*
How many times per week do you shampoo?*
Do you apply conditioning masks to your hair? How often?*
Do you use heat tools to style? If yes, do you apply a thermal protectant before you use them?*
Do you pull your hair back in tight ponytails? How often?*
Do you currently or have you worn hair extensions?*

YesNo
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 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
The programs and help I offer requires commitment. The results will very based on the level of commitment. Are you willing to stay committed and wait at least 6 months to see results with the program I create for you?*

YesNo
Is there anything else you would like me to know before booking your appointment?*
I am being evaluated at Root Revival 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 $175 consultation fee. 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 my commitment to the changes needed to be made and the use of products. 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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Hair Restoration Pre-Consult Form