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
What type of support are you seeking?
What are you experiencing? Shedding/thinning/bald spots/scalp symptoms/diagnosed alopecia/other
How long has this been happening?
Have you been diagnosed with a form of alopecia?
Have you seen a dermatologist?
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?
When would you like to begin?
Within 30 days
Within 1-3 months
Exploring options for later
If ongoing support is recommended after your assessment, my personalized program cost $4,997 over 6 months. Which better describes your situation?
I could consider this investment if the program fits my needs
I would need more information about the program and payment options
I am currently seeking an assessment
This investment is outside my current budget
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?
Submit
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