Clone of New Patient Enrollment Form

Got Roots Hair Growth Clinic - Intake Form

Our treatment program is designed to STOP HAIR LOSS, Strengthen & Start To Regrow Healthy Hair in just a few short weeks.
Every hair loss situation is different. This assessment form helps us gather a few details about your current situation. Once submitted, we will assess your information and review it with you at your scheduled consultation.
Before You Get Started - Please Take (3) Photos For Our Review

1. Top Area of Your Scalp - 2. Left Side Hairline 3. Right Side Hairline
Full Name*

First NameLast Name
Cell Phone Number:*
E-mail*
example@example.com
Date of Birth*

MonthDayYear
Date
Prefered Gender*

FemaleMale
What Is Your Current Height? (Feet & Inches) - This is required for the assessment.*
What Is Your Current Weight? (In Pounds) - This is required for the assessment.*
What Is Your Blood Type Group? - The RH Factor(+/-) Is not required for this question. *

ABABOI don't Know ItI would Like A Blood Test Done At My Appointment with $35 Add On Fee
How Did You Hear About Our Hair Loss Clinic?*
What are your main concerns dealing with hair loss?*
Do you currently take any prescribed medications for any of the following?*

AnxietyThyroidHigh Blood PressureDiabetesGastro IssuesIBSConstipationAcid RefluxMenopauseHormone Replacement TherapyBirth ControlOther
Please List Any Allergies You May Have or Have Been Diagnosed With. (This Is Important For Providing The Correct Treatment With Your Individualized Program).*
Are you allergic to Aloe Vera? Yes - No*

YesNo
Please List Any Illnesses You Have or Have Been Diagnosed With. (This Is Important For Providing The Correct Treatment With Your Individualized Program).*
Are you experiencing or have been diagnosed with any of the following conditions? *

PCOS - (Polycystic Ovarian Syndrome)EndometriosisAnemiaNo Current Conditions
Are you experiencing or have been diagnosed with any of the following scalp disorders?*

No Current Scalp ConditionsPsoriasis (Can Also Affect Your Eyebrows)Eczema (On the body or scalp)Seborrheic DermatitisDandruffOther
What areas of the scalp are you experiencing hair loss?*

(Only) My EdgesMy Hair Is Breaking Off(Only) My Crown Area; On The Top of My Head Is ThinningI Have Excessive Shedding(Only) My Middle Part Area; Is Getting WiderMy Hair Is Growing Out, But It Looks ThinnerBoth; My Front Hairline & Crown Are ThinningMy Hair Is No Longer Growing
How Long Ago Did This Issue For You Begin?*
What Was Going On When You Noticed The Hair Loss?*
Do You Have or Have Had An Itching, Burning or Tingling Sensation on Your Scalp? *
Yes or No / Which Area?
Do You Have A Hereditary/Family History of Hair Loss*
If Yes, Which Side Male or Female?
Any Recent Chemical Burns? *
If Yes - What Type? Relaxer / Color / Other
Have You Recently Had A Traumatic Experience?*

Life Stressors (Work, Home, Personal or Relationship Related)Had A BabyHospitalization / Surgical ProcedureWeight Loss Diet or ProcedureNoOther
Are You Currently Pregnant or Breastfeeding?*
Do You Smoke Tobacco Products?*

NoYesI am around 2nd Hand Smoke
Have You Tried Other Programs / Products In The Past?*

Hair Growth Oils/ Creams / GelsHair Growth VitaminsHair Growth ShampoosInjectionsLLLT - Low Level Laser TherapyPRP - Platelet Rich PlasmaRogain - RX or OTCOther
Have You Seen A Dermatologist In The Past?*

YesNoScalp ConditionAlopecia / Hair Loss
Were You Previously Diagnosed With A Type of Hair Loss By A Dermetologist or Doctor?*

NoYesScarring Alopecia - CCCA / FFAStyling Alopecia - TAHormonal Alopecia - TE / AGAAutoimmune - AAOther
According To The Hair Loss Scale; Which Hairloss Pattern Do You Have? (Draw on Image)
Please Upload Photo 1*

TOP OF YOUR HEAD
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Please Upload Photo 2*

FRONT HAIRLINE - LEFT SIDE
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Please Upload Photo 3*

FRONT HAIRLINE - RIGHT SIDE
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Once we recieve your online assessment. We will review it and see how we can help you. Our programs range from 3 - 6 months and require pre-scheduled in person visits to our clinic every 2 weeks for treatments. We see results pretty quickly. We document your journey and show proof of your progress. We do require you to be a compliant client and commit to a routine schedule.
What Day's Would You Be Available For Your Scheduled In Clinic Treatments?*

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
What Time Of Day Would You Be Available?*

Mornings (8am - 11pm)Afternoons (12pm - 3pm)Evenings (4pm - 7pm)
We Offer Different Programs & We Have Several Ways To Make Payments - Let Us Know If You Would Like More Information:*

We Offer Pre-Approved Financing Upto $4,000 (Let Us Know If You Are Interested)Do You Prefer (1) Single Payment? (Save $500 Off Regular Program Pricing)Are You Interested in No Credit Check / Extended Term Payments?Are you interested in Buy Now / Pay Later Options?Are you interested in (1) Down Payment & Monthly Plan Payments?Are you interested in (1) Down Payment & Bi-Weekly Plan Payments?
After you submit your form, You will be taken to the booking menu.

Please select your consultation appointment.

Once You Book Your Service. Your Meeting Link Will Be Sent To You.

Thank you for completing your assessment form.

We look forward to your RE-GROWTH with Us!
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Got Roots Hair Growth Clinic - Intake Form

Before You Get Started - Please Take (3) Photos For Our Review