Hair loss

1

Name

First Name

Last Name

2

Email

example@example.com

3

Phone Number

Area Code

Phone Number

4

Referred By

5

Please list any allergies

6

Please list supplements and medications

7

Are you vegan/vegetarian?

YESNO

8

Has this been sudden or gradual hair loss?

YESNO

9

Have you ever had a scalp biopsy?

YESNO

10

Do you pull your hair?

YESNO

11

Does hair loss run in your family?

YESNO

12

Have you been diagnosed with Alopecia Areata?

YESNO

13

Have you had a hysterectomy or are currently undergoing any hormone therapy?

YESNO

14

Have you had surgery or been pregnant in the past 6 months?

YESNO

15

Have you been diagnosed with an autoimmune disorder?

YESNO

16

Do you smoke or vape?

YESNO

18

What products are you using?

20

Signature

Clear