Hair Presence
Client Consultation Form
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
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Have you been recommended to Hair Presence by a friend? If so, please give their name here:
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What is your view of your hair loss?
*
Small amount of hair loss
1
2
3
4
5
6
7
8
9
Severe hair loss
10
1 is Small amount of hair loss, 10 is Severe hair loss
How does your hair loss affect you from day to day?
*
It doesn't
1
2
3
4
5
6
7
8
9
Causes me anxiety/depression
10
1 is It doesn't , 10 is Causes me anxiety/depression
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Have you researched a surgical option for hair restoration?
*
Yes
No
Why did you choose not to investigate or not to proceed with a surgical option?
*
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What is your occupation?
*
How physical is your job?
*
Not at all
1
2
3
4
Very
5
1 is Not at all, 5 is Very
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How often do you exercise?
*
How intensely do you exercise?
*
Very gentle
1
2
3
4
High intensity
5
1 is Very gentle, 5 is High intensity
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Would you say you are a person who is often naturally warm or sweaty?
*
Yes
No
Don't know
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Signature
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