Hair Replacement Application

Hair Replacement Application

Are You Ready To Take Back Your Confidence?
Hello Beautifu! Congratulations on taking the first steps toward reclaiming your confidence and finding the best hair loss solution for you.

Please take a moment to complete this quick application so I can learn more about your hair loss journey and be prepared for your consultation.

After you submit, I will review and get back to you within 24-48 hours to schedule a time for your in-person or virtual consult. Can't wait to meet you! Marcia
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
What is your preferred method of contact

PhoneTextEmail
Do you have an Instagram Handle?
Have you been diagnosed with hair loss or thinning by a medical professional?

YesNo
If yes, please share what you can about your diagnosis.
(For example, Alopecia, telogen effluvium, androgenic alopecia, post partum hair loss, etc.)
If "No" can you please describe your hair loss to help me better understand your unique situation?
How long ago did you first start to notice hair loss?
Have you tried any medical/clinical treatments or solutions such as medication, PRP, vitamins or oral/topical treatments/creams/shampoos, etc? If so, please list them and describe your experience and results.
What are your main concerns regarding your hair loss?

All over thinningReceding HairlineIsolated patches of thinning or baldnessLoss due to medical condition or result of treatment
What best describes the condition of your natural hair?

Healthy, but thinHealthy with some slight damage or dryness at the endsSlightly compromised, damaged from coloring, lighteningSignificantly overprocessed and experiencing breaking
Other than hair loss, do you have any other particular areas of concern?
Have you tried a hair replacement solution before?

YesNo
If yes, what have you tried and how was your experience?
For example: wigs, toppers, etc.
Do you have any known sensitivities to latex, adhesives, tapes or other hair enhancement products?

YesNo
What are you hoping to achieve with the addition of a hair replacement solution?
What kind of hair solution interests you?

Temporary, I want to be able to remove it when desiredPermanent, i want to be able to have hair 24 hours
Is there a specific hair replacement method that you are interested in learning more about? Please let me know below:
Are you aware that the investment in a hair solution can range between $1,500 to $5,000?

Yes, I am aware of the investmentNo, I had no idea
Hair Color
Is your hair currently colored?

YesNo
If yes, are you satisfied with the current color?

YesNo
If "No" what would you like to change about your color?

LigherDarkerMore dimensional or highlighted
Maintenance Time Commitments
All hair replacement methods require maintenance appointments to keep your hair and scalp healthy and to keep you looking your best. The times are determined on a case by case basis, but usually are every 4-6 weeks. These appointments can range from $75 to $300 depending on methods used. Would you be willing to commit to these maintenance appointments?

YesNo
Consultation Expectations
There is a $100.00 fee for consultations to be paid at time of booking your appointment. This can be applied to your new system if you choose to move forward.

You have the option to select a virtual or in-person consultation. However, please be aware that if you opt for a virtual consultation, an in-person consultation will have to be scheduled to determine colors, length, density etc.
Please upload an image of your current hair
Please upload an image of the hair that you want or your inspiration

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Hair Replacement Application

Hair Color

Maintenance Time Commitments

Consultation Expectations