Scalp & Hair Consultation Form

Scalp & Hair Consultation Form
Full Name*

First NameLast Name
Contact Number*
Please enter a valid phone number.
Email Address*
example@example.com
Address (for shipping purposes)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*
Sex*

MaleFemale
What is your occupation?*
Hair/Scalp Concerns (select all that apply)*

Dry ScalpItchy ScalpOily ScalpTension/Sore ScalpAlopeciaThinningTangles/Un-manageableMattingHair growth stagnant
Daily Stress Level*

1-low2-moderate3-some days high, some days low4-slightly stressed daily5-exploding with stress
How often are you cleansing your hair & scalp?*

every dayevery other dayevery 3 daysevery 4 daysevery 5 daysevery 6 daysonce a week7+ days
What shampoo are you using?*
Other than shampoo list EVERY other product you currently use either on your scalp or hair. Nothing is too specific.. include Brands + Names/Any helpful information*
What is your current drying method?*
How often are you applying additional heat to your hair? (Curling irons/flat irons/crimpers/blow dry brushes)*
How often are you pulling your hair back into pony tail holders? And what are you using? (Claw clips/scrunchies/is it braided?) There is no such thing as too much information.*
Medical Conditions (select all that apply):*

PregnantNursingLess than 2 years post partumDiabetesHypothyroidismHyperthyroidismHigh blood pressureAllergies (food or enviromental)High blood pressureHeart diseaseEczemaPsoriasisDandruffUnlisted auto-immune diseaseCancer
Any unlisted medical conditions?
Have you been under anesthesia within the last 3 months?*

YesNo
List any allergies:
If you could change anything about your hair and/or scalp, what would it be?*
How much time are you looking to spend on this goal daily?*
What aligns with your budget for a new product regimen?*
Is there anything else you can think of that you want me to know? <3
Please upload 3 clear, well-lit photos of your hair & scalp (you may need to rope in an assistant for this ;) )*
Take Photo*
Take Photo
I have provided accurate information to the best of my knowledge and understand that Abigail Wolf's (of SLEEK Hair Salon & Scalp Spa LLC) advice and product recommendations is not a substitute for medical treatment or advice.

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Scalp & Hair Consultation

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