Consultation for Skincare

1
What is your preferred date of visit?* This field is required.
2
Full Name* This field is required.
First Name
Last Name
3
Date of Birth* This field is required.
Month
Day
Year
4
Email Address* This field is required.
example@example.com
5
What service are you interested in?
Skincare
Hair Regrowth
6
Are you under the care of a dermatologist?
Please Select
Please Select
Yes
No
7
Do you smoke?
Yes
No
8
Which Topical Topical Treatments, Other Treatments, and Oral Supplements you are currently taking/using or have taken/used in the past. Check all that apply.
Minoxidil (Rogaine)
Finasteride (Propecia)
Other Treatment: Platelet-rich plasma (PRP)
Other Treatment: Injections
Other Treatment: Exosome Therapy
Oral Supplement: Nutrafol
Oral Supplement: Biotin
Sprays & Serums
MaryRuth's Products (Liquid Morning Multivitamin + Hair Growth and Hair, Skin & Nails Gummies)
None of the above
9
What are your current hair care regimen?
Huge
Large
Normal
Small
Ok
Ok
10
Is your hair:
Oily
Dry
Normal
11
What are your skincare goals?
12
What is your current skincare regimen?
13
How much water are you drinking daily?
14
What are your diet consist of?
15
Is your skin oily, dry, normal or sensitive?
16
Appointment Deposit * This field is required.
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My Bag
1
My Bag
Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
ORDER SUMMARY
Total costUSD
1-Hour Appointment DepositReserve your 1-hour session with a non-refundable deposit of $100.
$100.00Edit
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Total cost $0.00
Payment Methods
Credit Card
First Name
Last Name
Apple Pay
After submitting the form, you will be redirected to the Apple Pay to complete the payment.
17
Signature* This field is required.
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