Hair Loss Form

Hair Loss Form
Have you had hair extension before? Or Hair replacement before*

YesNoOther
Are you interested in? *
What texture best describes your hair?*

FineMediumThickStraightCurlyFrizzyWavyOther
Do you have any scalp/hair loss concerns?*

Dry ScalpOily ScalpHair ThinningHair LossColour DamageHeat DamageOther
How often do you wash your hair?*

Daily2-3 times a weekWeeklyFortnightly
What is your main area of concern?*

HairlineCrownAll over
Do you currently suffer from any of the following?*

AlopeciaHair LossThinningCancer TreatmentSurgeriesPsoriasisDry Flaky ScalpTrichotilomaniaNone of the above
Are you any of the following?*

PregnantMenopauseUndergoing TreatmentTaking any medicationNone of the above
If you selected "Taking any medication" please give more details.
We understand this process is a very personal journey, Do you have any questions or concerns ?
Are you able to commit to 4-6weekly maintenance appointments?*

YesNo
On your first install are you happy to have videos and photos taken to monitor your progress ?*

YesNoSalon records onlyTo share on socials to help others
What length are you wanting to achieve?*

Above shoulder, 14 inchBelow shoulder, 16 inchBra strap length, 18-20 inchWaist length, 24 inch plus
Please upload two current pictures of your hair*

Cancelof
Any inspiration pictures please upload

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Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: 00000000000.
Should be Empty: