Hair loss consultation
Signature Scalp consult form
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
How long have you suffered with any type of hair loss/ thinning?
What area did you first notice your hair loss?
Has your hair loss progressed quickly, or has it been a gradual process?
Have you ever been medically diagnosed with a hair loss condition or seen a trichologist?
Have you had any other hair replacement system or hair extensions?
Have you ever had a hair transplant before?
Do you have a history of hair loss / hair thinning in the family?
Do you suffer from psoriasis or eczema?
Do you consider yourself to have a sensitive scalp?
Are you pregnant or have you given birth in the last 12 months?
Do you smoke?
Do you eat a healthy balanced diet?
Do you take regular prescription medication?
Do you have any known allergies?
Do you use sunbeds/ gym/ swimming or have vacations booked?
Are you using signature scalp (if we proceed)for cosmetic or medical purposes?
Signature
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Should be Empty: