CRLAB Form

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Thank you for your interest in our specialized hair regrowth consultation. We understand the importance of healthy and vibrant hair and are excited to embark on this journey with you. Before we begin, your well-being is our top priority, and our comprehensive consultation form is designed to gather essential information about your scalp and hair health. By sharing your concerns, history, and preferences with us, you're taking the first step toward personalized and effective hair regrowth treatments. Rest assured, our experienced team is here to guide you through each stage, ensuring your journey to revitalized locks is both enjoyable and tailored to your unique needs. Let's embark on this transformative experience together!
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Name
First Name
Last Name
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Email
example@example.com
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Phone Number
Please enter a valid phone number.
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When did you first start experiencing hair loss?* This field is required.Month/Year
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How would you describe the progression?* This field is required.
Gradual thinning
Sudden shedding
Patchy/bald spots
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What areas are affected?* This field is required.Select all that apply
Crown
Hairline
Sides/temple
Overall thinning
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Have you been formally diagnosed with a hair loss condition?* This field is required.If yes, please tell us your diagnosis below.
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If you answered yes to the previous question, who were you diagnosed by?* This field is required.
Dermatologist
Trichologist
I have not been diagnosed
Other
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Do you have a family history of hair loss?* This field is required.If yes, please explain,
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Do you have any current or past medical conditions that could contribute to hair loss? If yes, please explain.* This field is required.E.g., Autoimmune disorders, hormonal imbalance, thyroid issues, alopecia areata.
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Have you experienced recent significant stress or trauma?* This field is required.If yes, please share as much as you're comfortable with
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Have you undergone any surgeries, chemotherapy or radiation treatments?* This field is required.If yes, please provide details.
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Please list any current medications/supplements* This field is required.
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Diet and nutrition habits:* This field is required.
Balanced
Restrictive
Irregular
Other
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Have you tried any hair loss treatments or solutions before?* This field is required.Please select all that apply.
Topical (minoxidil, serums, oils)
Oral (finasteride, supplements)
Laser therapy
Hair transplant
Wigs/hairpieces/extensions
Other
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Are you currently wearing a wig or hairpiece?* This field is required.If yes, what type?
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If you answered yes to the previous question, how long have you been wearing your wig/hairpiece?* This field is required.
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What do you like/dislike about your current solution?* This field is required.
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What is your daily activity level?* This field is required.
Low (minimal exercise)
Moderate (light activity, walking)
High (sports, gym, swimming)
Type option 4
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Do you need a hair prosthetic that is waterproof?* This field is required.
YESNO
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How important is low-maintenance styling to you?* This field is required.
Very important
Somewhat important
Not important
Type option 4
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What is your desired length?* This field is required.
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What is your desired color?* This field is required.
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What is your desired density?* This field is required.
Light
Medium
Full
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How do you typically style your hair?* This field is required.E.g., blow-dry, air-dry, curl, straighten
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How is hair loss affecting your confidence or daily life?* This field is required.
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Why do you want to invest in a CRLAB hair prosthetic at this time?* This field is required.
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What would the ideal outcome look like for you?* This field is required.
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Are you ready to commit to the recommended maintenance schedule?* This field is required.Every 4 weeks
YESNO
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Are you prepared for the investment cost?* This field is required.
YESNO
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Please share any more information you would like for me to know.
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Signature
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