Hair Loss Intake Form

Hair Loss Intake Form

Welcome to Blond Bungalow’s mesh Integration Consultation Form We’re so glad you’re here. This form is designed to help us understand your unique hair loss experience and determine if BB Crown Integration is the right solution for you. Your answers will remain confidential and will help us create a customized plan that supports your hair goals. Please take a few minutes to fill out the form below. Once submitted, we will review your information and contact you to schedule a virtual consultation.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
When are you hoping to get an appointment by

MonthDayYear
Date
1. How long have you been experiencing hair loss or thinning?
2. Do you know the cause of your hair loss? (Select all that apply)
3. Have you consulted a doctor, dermatologist, or trichologist about your hair loss?
4. If yes, what diagnosis were you given?
5. Are you currently taking any medications, supplements, or undergoing treatments that could affect your hair? (This can include things like thyroid medications, hormonal therapy, chemotherapy, etc.)
6.. Are you currently shedding hair?
7. Do you experience any of the following?
8. Have you tried any of the following solutions?
9.What is your current hair care routine? How often do you wash and style your hair?
10. What is your ideal result from this service? Examples: Full coverage, volume at the crown, natural appearance, low maintenance, ability to style hair, etc.
Upload Current Hair Photos (Optional but Helpful) upload 2-3 recent photos of your hair (front, side, and top views)
11. Do you engage in physical activities or sports that require a secure hair solution?
12. Have you lost all your hair due to chemotherapy or alopecia? In cases of total hair loss, BB Crown Integration may not be the best option. Instead, we offer custom-made wigs tailored to your exact sizing and needs. We partner with a skilled wig maker in the UK who creates beautiful, high-quality wigs made to order. would you like to consult and get fitted for a custom made wig?
Thank you for taking the time to share your information with me. I know how personal and emotional the experience of hair loss can be, and I want you to know that you’re not alone. I’ve walked this journey myself and I understand how challenging it can feel. I’m truly grateful for your trust in allowing me to be part of your hair restoration journey. I look forward to connecting with you and supporting you every step of the way.

Maritza
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