• Elevate Mesh & Meshless Integration Consultation

    Share your hair loss history, goals, and photos to schedule your custom mesh or meshless integration consult.

  • Client Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Consultation Goals and Hair Loss History

  • Consultation goals*
  • When did hair loss start?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Did the hair loss develop gradually or suddenly?*
  • What are you noticing?*
  • Which areas are affected?*
  • Have you seen a dermatologist?*
  • Have you had a scalp biopsy?*
  • Family history of hair loss

  • Medical History

  • Payment Information

  • We accept HSA, FSA, all major credit cards, Afterpay, Zelle, Cash App, and cash. All consultation fees are paid in full before the appointment. If insurance reimbursement is available, reimbursement occurs afterward and is the client's responsibility.
  • Are you currently experiencing menopause or perimenopause?*
  • Have you been diagnosed with a thyroid condition?*
  • Have you been diagnosed with polycystic ovary syndrome (PCOS)?*
  • Have you been diagnosed with anemia or iron deficiency?*
  • Have you been diagnosed with an autoimmune disorder?*
  • Have you ever been diagnosed with alopecia?*
  • Have you received chemotherapy treatment?*
  • Have you received radiation treatment?*
  • Have you had any recent surgery?*

  • Policies & Acknowledgements

  • Have you had any significant illness or hospitalization recently?*
  • Are you taking any weight loss medication?*
  • If yes, which weight loss medication are you taking?
  • If yes, when did you start the weight loss medication?
  • Are you currently using hormone therapy?*

  • Lifestyle and Scalp Health

  •
  • Dietary pattern
  • Do you smoke or use nicotine products?*
  • Do you pick at your scalp?*
  • Do you pull or twist your hair?*
  • Current scalp symptoms
  • Scalp or skin conditions diagnosed by a professional
  • Do you experience scalp itching?
  • Do you experience scalp burning or stinging?
  • Do you experience scalp tenderness or pain?
  • Do you notice scalp redness?
  • Do you notice flaking or dandruff?
  • Do you notice excessive scalp oiliness?
  • Do you notice scalp dryness?
  • Do you notice any scalp odor?
  • Have you had any recent scalp infections?

  • Hair History and Current Practices

  • Natural hair texture*
  • Is your hair color treated?*
  • Have you had bleach or lightening services?*
  • Chemical services used on your hair
  • Have you worn extensions before?*
  • Current or past use of wigs or toppers
  • Daily styling habits
  • How often do you use heat on your hair?*
  • Hair care products you use regularly

  • Photo Uploads and Budget

  • Upload a File
    Drag and drop files here
    Choose a file
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  • Upload a File
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    Choose a file
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  • Upload a File
    Drag and drop files here
    Choose a file
    Cancelof
  • Upload a File
    Drag and drop files here
    Choose a file
    Cancelof
  • Upload a File
    Drag and drop files here
    Choose a file
    Cancelof

  • Consultation Agreement and Payment

  • Consultation Fee*

    prevnext( X )
      Elevate Mesh/Meshless Integration Consultation


      $250.00$250.00
        
      Total
      $0.00$0.00

      Payment Methods

      creditcard
      After submitting the form, you will be redirected to Apple Pay to complete the payment.
      After submitting the form, you will be redirected to Google Pay to complete the payment.
      After submitting the form, you will be redirected to Cash App Pay to complete the payment.
      After submitting the form, you will be redirected to Afterpay to complete the payment.
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