Hair/Scalp Consultation

Hair/Scalp Consultation

Welcome! My name is Michelle Lutz and I am a certified Hair Loss Practitioner and anti-aging haircare expert. I have dedicated over 200+ hours of research on haircare, scalp, and product knowledge. My standards are very high for hair and scalp care products: PROVEN RESULTS from clinical studies, backed by UNIVERSITY OF MIAMI MILLER SCHOOL OF MEDICINE PAUS LAB, and industry-leading hair/scalp scientists Antonella Tosti and Ralf Paus, PREMIUM and SAFE INGREDIENTS (sulfate-free, clinically tested, leaping bunny certified, paraben free, vegan, gluten-free, non-soluble silicone-free, high quality surfactants, safe colorants, safe fragrances) and EUROPEAN INGREDIENT STANDARDS with no formulation changes world-wide, and budget friendly. Thank you for trusting me with your haircare and scalp needs. I look forward to connecting with YOU!
Email*
example@example.com
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you 18+ years old (or have parent permission)?*

YesNo
How did you find me?*

InstagramFriend/Family ReferralFacebookOther
My Hair Length Is...*
My Hair Is...*

Color-treatedBleached regularlyStyled using heat regularlyNatural colorThinningOther
My Hair Thickness Is...*

FineNormalThick/Coarse
Based on the picture above my HAIR TEXTURE most closely resembles:*
If your hair is curly, do you...

Wear your curls naturalUse heat to straighten, blow out, or smooth out your curlsDo a bit of both
My Scalp Is...*

Oily - no dandruffOily - sticky/yellow dandruffDry - no flakesDry - white flakesMy scalp is neither dry nor oily
I wash my hair with shampoo...*

DailyEvery other dayTwice a weekOnce a week2/3x a month1x a month
My Hair Is Naturally...*
I use hot tools...*

NeverSometimesOften
What are your hair or scalp concerns?*
Your Top 3 Hair Concerns:*

damage from bleach or hot toolsfrizzoily scalp (have to wash too often)ultra dry hair that seems to need nourishmentthinning hair that needs more regrowth/thickeningflat (but healthy) hair that needs volumizingblonde is too "brassy"I don't have a major hair concern, I just want to use better and safer quality haircareOther
If I could fix one thing about my hair it would be...*

minimize damage/frizzbe able to wash less times per weekhydrate my endsthicken/regrowadd volume to rootsbrighten my hair colorI don't have a major hair concern, I just want to use better and safer quality haircareOther
I have noticed more hair shed/hair loss...*

YesNo
If you answered YES above please answer the questions below: *
1. What is your gut health like? Do you struggle with constipation/diarrhea? 2. Do you have autoimmune condition(s)? 3. Any recent changes to medications? Specifically medications that may be changing your cortisol production. 4. To your knowledge, is your liver functioning normally? Do you still have your gallbladder? 5. What is your diet like? Are you getting enough nutrients/protein? Has your diet recently changed, was it a drastic change? 6. 2-3 months prior to noticing your hair loss, did your body go through any stressful event (i.e. give birth, chemotherapy, sickness, death in family, school/work/home stress, etc.)? 7. Have you gotten your blood-work done?8) Please describe anything else related to your hair loss that you may consider a factor, or any medications/products/etc. that you've been recently using to try and tackle your hair loss. 9. What is your age?
Any medical scalp conditions that you are aware of? (i.e. psoriasis, eczema, etc. please be specific) or N/A*
Anything else you'd like Michelle to know about your hair/scalp goals?*
My USD budget for a 4-6 month supply of my future custom hair/scalp care system...*

$150 (this is the minimum)$230$270+No budget. I need major help.
Your Cell Phone Number:*
Your Instagram Handle?*
example: @michellelutz
Please note, after submitting this form you will be contacted by Michelle with any further clarifying questions to help you reach your hair/scalp goals, product details, professional haircare recommendations, and directions to help you set up your account.*

Great! I understand that this is a consultation in which Michelle will take time to customize a haircare system for my specific needs free of charge. She will contact me within 48 hours with the information above! Consistently and accurately using the correct products for my specific needs will improve my desired results! I'm excited to see the recommendations!
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