Trichology Consultation
Includes 45-60 minute in-depth hair and scalp consultation, analysis summarization, plan of action, and 15 minute follow-up appointment.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Age
*
Birthday
-
Month
-
Day
Year
Date
How long have you been experience hair loss or scalp issues?
Where are you experiencing hair loss?
The top
The sides
The Back
Temples
Do you have symptoms on the scalp (itching, pain, burning)
Burning
Tenderness
Pain
Burning
Does anyone in your family experience hair loss?
Have you had any serious illness at anytime before or during hair loss?
List any any medications that you are currently taking:
Have you been hospitalized at anytime before or during the hair loss?
Have you been under a severe amount of stress at any time before or during the hair loss?
Have you started any special diets at any times before or during hair loss?
Do you have regular menstrual cycles?
Yes
No
Are you experiencing menopause?
Yes
No
Have you taken birth control to regulate your menstrual cycles
Yes
No
Have you seen a dermatologist about the condition?
Yes
No
If you so what was your diagnosis?
What is your hair care routine? Styles and products you use.
Have you had any blood test done to evaluate your hair loss?
Have your hormones been checked and evaluate your hair loss?
Have you been told by a doctor that you have a thyroid condition?
Have you ever been told by a doctor that you have iron deficiency?
Have you any autoimmune disorders/ diseases. If so list.
Is there any other important information you would like to share regarding your hair loss?
Upload up to 5 pictures of the problem area in a well-lit area. Take up-close pictures to see your follicles, and take distant pictures to see the full surface area of the problem area.
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Trichology Consultation
$125.00
$
125.00
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