Consultation Form
Let us know how we can help you!
Full Name
*
First Name
Last Name
Contact Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Emergency Contact
First Name
Last Name
Phone Number
Please enter a valid phone number.
Consultation type
*
Please Select
Virtual
In-person
What type of Hair Unit are you interested in ?
*
Have you had a Hair Unit before ?
*
Please Select
Yes
No
Please list in details Hair loss experience.
Please upload front ,back and side profile of your current hair.
*
Browse Files
Drag and drop files here
Choose a file
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of
Please upload type of style you’re looking to get with the Hair Unit.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
How soon are you looking to get serviced ?
*
Have you ever been treated for any hair or scalp problems ?
*
Please Select
Yes
No
Please list any other Hair replacement alternatives you had before.
*
What is your main goal? Select all that apply
*
Fill in the area where you have the hair loss.
Not wear hats all the time
Seeking a temporary look for an occasion
Being able to wear normal haircut again
How active is your lifestyle? (Workout activities )
*
Please Select
None
1-3 times a week
4-7 times a week
Have your ever had any bleeding disorders?
*
Please Select
Yes
No
Have you ever had an allergic reaction to anything put on your skin ?
*
Please Select
Yes
No
If yes , please list here.
If you have any concerns or questions please list them here.
*
Are you financially able at this time to do something about your hair loss ?
*
Yes
No
Financing is Needed
Should be Empty: