Hair thinning/loss consultation form

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Youtube
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Name* This field is required.
First Name
Last Name
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Phone Number* This field is required.
Please enter a valid phone number.
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Email* This field is required.
example@example.com
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Please enter: height, weight, full date of birth* This field is required.
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How did you hear about I.C. Beauty* This field is required.
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Have you been diagnosed with, or suffer with any of the following:
Stroke
Congestive heart failure
Hypertension
Coronary artery disease
Anemia
Depression
Thyroid disease
Endocrine disorders
Diabetes
Liver disease
Rosacia
IBS
Chromes disease
Autoimmune disease
Acid reflux
Constipation/diarrhea
Cancer
None of above
Other
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Are you having at least 2 bowel movements a day?* This field is required.
If not daily indicate how many a week
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Please list supplements and medications taken or enter none* This field is required.
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Females- any menstrual issues?
Yes
No
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Females- are you pre/post menopausal?
Yes
No
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Females- planning pregnancy in next 6 months?
Yes
No
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Females- Currently pregnant or nursing?
Yes
No
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Females- are you taking contraceptives?
Yes
No
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Do you have Redness or itchy scalp?* This field is required.
Yes
No
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Do you pull your hair?* This field is required.
Yes
No
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Do you have bumps or raised areas on the scalp?* This field is required.
Yes
No
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Do you have recurring patchy hair loss?* This field is required.
Yes
No
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Have you ever had any issues related to vaccinations* This field is required.
Yes
No
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Does hair loss run in your family?* This field is required.
Yes
No
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Hereditary
Bald
Thinning
Patches
Unknown
Parents
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Grandparents
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Siblings
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Aunt
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Row 3, Column 3
Uncle
Row 4, Column 0
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Parents
Grandparents
Siblings
Aunt
Uncle
Bald
Row 0, Column 0
Thinning
Row 0, Column 1
Patches
Row 0, Column 2
Unknown
Row 0, Column 3
Bald
Row 1, Column 0
Thinning
Row 1, Column 1
Patches
Row 1, Column 2
Unknown
Row 1, Column 3
Bald
Row 2, Column 0
Thinning
Row 2, Column 1
Patches
Row 2, Column 2
Unknown
Row 2, Column 3
Bald
Row 3, Column 0
Thinning
Row 3, Column 1
Patches
Row 3, Column 2
Unknown
Row 3, Column 3
Bald
Row 4, Column 0
Thinning
Row 4, Column 1
Patches
Row 4, Column 2
Unknown
Row 4, Column 3
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Have you dealt with any trauma or stress (stress could apply to good changes as well like marriage, baby, job promotion,etc) in the past 12 months?* This field is required.
Yes
No
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If Yes, Please explain these stresses a little more. Stresses to the body include surgeries as well
Huge
Large
Normal
Small
Ok
Ok
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What's your blood type?
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Please describe your eating habits? Ex. Sugar intake, how many meals a day, how much water daily, amount of dairy, main source of protein, alcohol intake
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What hair recovery options have you researched:
Laser therapy
Non surgical hair replacements
Over the counter products
Prescription mediciations
PRP
Scalp micropigmentation
Holistic therapy
Other
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What expectations of results do you have
Prevent further loss
Gain hair back quickly
Gradually gain back
Better coverage
Other
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Are you on any weight loss medications, or have had a weight loss surgery?
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What do you do to manage stress levels?
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Do you prefer virtual or in person? The consultation will take about 1- 1.5 hours. The investment is $175 which includes your custom Jumpstart kit. (Virtual clients will be responsible for shipping cost) A deposit of $50 is required to book. Once form is submitted invoice for deposit will be sent to the email listed* This field is required.
In person
Virtual - zoom link will be sent
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Knowing treatment may take 6 months or more to show success are you willing to wait patiently* This field is required.
Yes
No
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Are you ready to make some difficult life changes now to see the results you desire later?
Yes
No
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Budget is very important to consider during this process. During this upcoming visit we will discuss which tier your hair loss falls into. The length of time in treatment, and the protocols suggested is what varies from tier to tier. Below please select your comfortable MONTHLY budget range. My goal will be to customize your treatment as best as possible to what you will be able to commit to* This field is required.
200-400
400-600
650-900
950-1300
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By signing below, I agree to be evaluated by Iisha Silver, a certified Hair and Scalp Specialist. I understand that this evaluation will determine if I'm a suitable candidate for a personalized treatment protocol. I further understand that each person is different, and results may vary. I will notify Iisha of changes of medications or health issues. Pictures may be used for before and after results, face will be kept confidential unless client gives permission for individual testimonial. Bio resonance scanning is done during visits that produce reports and sound therapies. I understand that Iisha IS NOT a medical doctor and DOES NOT claim to diagnose or medically treat illnesses.
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I'm here to serve as a guide on a most difficult journey to recover the hair and self esteem that diminishes daily the longer you endure your hair/scalp obstacle.

if you're ready, I'm ready. 🤗
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