I Need A Trichologist Seminar Profile Form

Seminar Profile Form
The purpose of this form is to understand any hair loss issues you are having so that we can properly address your situation.
Date

MonthDayYear
Date
Name*

First NameLast Name
Age*
Under age 18 does not qualify.
Please select if applicable:

I am under the age of 18.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Do you plan on attending a Hair Loss Seminar? If so, which city?*

Columbus, GA- Saturday, December 7th at 11:00 amNo, I will not attend a Hair Loss Seminar.
Hair Care History Questionnaire

Have you ever encountered alopecia or hair loss of any kind? Hair loss has become a common phenomenon, and it can have a variety of causes, including traction alopecia and follicular degeneration syndrome.
What hair care services do you usually require? Check all that apply:

Hair Scope AnalysisShampoo Style & HaircutFlat Iron or Curling Iron StylingHair Color with BleachSemi-Permanent Hair ColorTemporary Hair ColorHenna Hair ColorHair Color RinseDemi Permanent ColorChemical Hair RelaxerHair Straightening SystemsPermanent WaveHair Weaving Sew-inQuick WeaveSynthetic Hair WeavesHuman Hair WeavesVirgin Human Hair WeavesRemy Hair WeavesHair Weaving Bonding with GlueHair Weaving Lace FrontalHair Weft Fusion Hot FusionHair Weft ColdFusionHair Weft Clip-InsHair NettingHair Graphing/PlugsHair TransplantationBraidsCrochet BraidsTree BraidsMale/Female Non-surgical Hair PlacementLocs (Traditional Locs, Sisterlocs, Microlocs, Semi-freeform Locs, Freeform Locs, or Florida Wicks)Human Hair WigsSynthetic Hair WigsScalp Micropigmentation SMPNone of the above
What issues have you had with your hair/scalp? Check all that apply.

Hair Loss Bald SpotsHair Thinning and DiffusionAlopecia AreataTraction AlopeciaFlakingItchingPain/irritationBeard issuesNone of the above
DISCLAIMER: The National Trichology Training Institute only provides precautionary measures and knowledge to possibly prevent the progression of hair loss among millions of people in our society. However, the National Trichology Training Institute (hereafter referred to as NTTI) and Connie Judge assume absolutely no liabilities for any injuries resulting from information provided in this consultation to students or consumers. Individuals knowingly and willfully assume all such risks and responsibilities upon themselves and hold harmless NTTI and Connie Judge and any parties associated with NTTI with respect to all hair loss issues and health issues, whether arising from negligence of NTTI or otherwise.
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