Form
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What type of support are you seeking?
Initial hair/scalp assessment
Ongoing personalized support
Unsure, I need help deciding
Which of the following hair or scalp concerns are you currently experiencing? Select all that apply.
Which of the following hair or scalp concerns are you currently experiencing? Select all that apply.
Excessive shedding
Hair thinning or decreased density
Receding hairline or thinning edges
Bald spots or patchy hair loss
Scalp itching, burning, tenderness, or inflammation
Flaking or scaling
How long have you been experiencing your hair or scalp concerns?
Less than 3 months
3-6 months
6-12 months
1-3 years
More than 3 years
I'm unsure
Have you received a medical diagnosis for your hair loss or scalp condition?
Yes
No
I'm currently undergoing evaluation
I'm unsure
If you replied yes to the above question, what was your diagnosis?
Have you previously worked with a healthcare or hair loss professional regarding your concerns? Select all that apply.
Dermatologist
Primary Care Physician
Trichologist
Other healthcare professional
No, this is my first time seeking professional guidance
What have you tried already, and what results did you experience?
Do you have recent bloodwork within the last 90 days?
If ongoing support is appropriate, are you open to making recommended nutrition/lifestyle changes and participating in scheduled follow-ups?
Yes
Possibly- I need more information
Not currently
What outcome are you hoping for?
How soon are you prepared to begin investing in professional guidance to address your hair loss?
Immediately — I'm ready to take the next step.
Within 30 days — I'm preparing to begin.
Within 1–3 months — I'm considering my options.
I'm gathering information and not ready to invest at this time.
Our comprehensive Hair Loss Consultation is $397. This includes an in-depth assessment to better understand your hair loss concerns and identify potential contributing factors.For clients who would benefit from ongoing support, personalized wellness programs begin at $4,997, with payment options available. Program recommendations are based on your individual needs and assessment findings.
I'm prepared to invest in my consultation and ongoing care if recommended.
I'm prepared to invest in my consultation and would need payment options for ongoing care.
I'm ready to invest in the consultation but not ongoing care at this time.
I'm not financially prepared to invest in professional services at this time.
The Hair Mayven & Wellness currently provides consultations and hair loss recovery support virtually. Are you comfortable receiving your services through virtual appointments?
Yes
Yes, but I have a few questions about how virtual services work.
No, I am specifically looking for in person services.
How did you hear about The Hair Mayven & Wellness?
Is there anything else you would like me to know about your hair-loss journey, healthy history, or what you're hoping to accomplish by working together?
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