First Service Request Form

1

Thank you for considering me to assist you in addressing your beginning to moderate hair loss. This form will ensure that I can accommodate your specific hair loss concerns and provide you with a clear idea of what to expect in terms of cost.

I typically respond to inquiries within 12-24 hours. Please check your spam inbox if you don't see a response in your main inbox.

Reclaim your hair reclaim your confidence

2

Name* This field is required.

First Name

Last Name

3

Email* This field is required.

example@example.com

4

Phone Number* This field is required.

Please enter a valid phone number.

5

Date Of Birth * This field is required.This helps me identify with what type of hair loss you may be experiencing

Date

6

Gender* This field is required.

Female

Male

7

Are you willing to get blood work done? * This field is required.Blood work is needed to check for hormonal imbalances, vitamin and mineral deficiencies as well. These contribute to hair loss issues most people experience. This also helps with sustaining hair regrowth.

YESNO

8

Are you currently diagnosed with cancer, pregnant or going through chemotherapy?* This field is required.If so, I will not be able to provide treatment services for you at this current moment. Thank you for your consideration, maybe sometime in the future.

YESNO

9

Do you have a diagnosed scalp disorder?* This field is required.

YESNO

10

Stages Of Hair Loss

11

From the previous chart what number do you most identify with and how long has it been at this stage?* This field is required.Choose whichever number is closest to what your current state of hair loss is, even if you don't have male or female pattern.

12

Where are you experiencing hair loss, thinning or damage?* This field is required.This helps me identify what type of hair loss you may have and need treatment for.

Top of head

Hairline

Crown area

Other

13

What type of Pattern of hair loss do you have?* This field is required.If you have been to a dermatologist or doctor and have a diagnosis please select which one you have.

Male/Female Pattern Hair Loss

CCCA Alopecia

Diffused (Hair loss and thinning all over)

Alopecia Areata (patchy hair loss)

Traction Alopecia (Hairline)

Not Sure

14

Is the condition getting worse?* This field is required.

YESNO

15

Next Step

To help you reach your hair regrowth goals, we start with an in-clinic consultation. I ask prospective clients, including those I haven't worked with for over a year, to begin with a one-on-one consultation with Alexis before diving into treatment. This allows us to assess your hair and scalp issues, address your concerns, and understand your unique goals to create a personalized treatment plan.

Please note: Consultations and deposits are non-refundable and serve as a deposit towards Treat's services.

16

A $160 deposit is due at the time of booking for the consultation's and products.The deposit will be deducted off of your balance after services are rendered.

17

A deposit of $350 deposit is due at the time of booking.

18

Based on the service offerings, which service would you need?* This field is required.Remember after you submit this form you will receive an email with instructions on how to book your appointment.

Premium Consultation & Product Bundle

Premium Consultation, product bundle & A Stem Cell Treatment