Medical Hair Loss Consultation Form
We understand that the experience of losing one's hair can be deeply impactful on their confidence and sense of self. We're here to help you find a safe and comfortable solution that works best for you and your lifestyle.
Full Name
*
First Name
Last Name
Date of Birth
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
E-mail
*
example@example.com
MEDICAL HISTORY
Are you currently receiving any form of medical treatment for your hair loss? If yes, please specify:
When did you start noticing hair loss:
Has your hair loss been diagnosed by a medical professional? If yes, please specify diagnosis:
Are you currently taking any medications for hair loss? If yes, please list them:
HAIR LOSS DETAILS
Description of current hair condition (e.g., thinning areas, total hair loss):
What are your specific areas of concern?
Are you experiencing scalp irritation?
Yes
No
Sometimes
Which of the following you have tried: extensions, hair fibers, hair topper or wig. Please describe your experience.
What, if any, is your biggest worry about wearing extensions, fibers or a topper?
LIFESTYLE & NEEDS
Please identify any lifestyle and daily activities that may effect your hair (e.g., working out and sweating, have to wear your hair up for work, need frequent MRIs/ scalp injections):
Hair Goals
Describe your ideal outcome (e.g., volume, coverage, style):
What is your desired look and how do you typically style your hair?
What hair products and styling tools do you currently use to style your ahirHow often do you wash your hair?
SUBMIT FORM
Should be Empty: