Hair Loss Consultation Form

Hair Loss Consultation Form

Please answer these questions as honest as possible, this will help me determine your potential causes for your hair loss concerns. Please choose a date and time that works best for you, I will text or call with a confirmation of acceptance.
Name

First NameLast Name
Date of Birth

DayMonthYear
Gender
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Is hair loss a recent concern ?
Have you ever tried hair growth products before?
Which program and products have you used and for how long?
Have you seen a dermatologist for your hair loss concerns?
Has anyone in your family experienced hair thinning or balding?
Please list all family members , male and female
Do you drink alcohol? ( No judgement, just need to know )
Do you do drugs? ( No judgement, just need to know )
Do you smoke or vape? ( No judgement, just need to know )
Are you taking any medications?
Have you had any recent surgery or procedures done?
Have you had any recent weight loss or weight gain? ( 6 months-1 year)
Are you on any weight loss medication or shots?
Are you experiencing menopause?
Are you currently pregnant, planning to get pregnant or breastfeeding?
Do you have any heart problems ?
Are you allergic to shellfish ?
Do you have self discipline ?
Do you eat a lot of protein ?
Do you exercise ?
Do you have children?
Please list all health diagnoses, suspicions and allergies
When was your last physical and or lab work done ?
Please rate your stress level from 1-5 (5 being extremely stressed)
Please rate how healthy you eat daily 1-5 ( 5 being extremely health conscious )
How often are you wearing your hair in a tight hairstyle , or the same hair style often?
Please list shampoo and conditioner your currently using, also leave in products
How often do you goto the salon for chemical services like hair color, relaxers, perms or extensions ? And if so which services?
Please add any additional comments or concerns
Preferred Appointment Date

My Products

Hair Loss Consultation ( ONLINE )

30-45 min phone or video call to discuss hair loss concerns, creating a customized treatment plan of action.

$68.00 Quantity
Item subtotal:

Total

Payment Methods

Credit Card

Apple Pay

Google Pay

Cash App Pay

ACH Bank Transfer

Afterpay

Should be Empty: