Health Assessment

I am being evaluated by Hair Loss Practioner Leia' Love of Leia' Love Hair Restoration LLC (LLHR LLC). I understand the success of my therapy depends 100% on my compliancy to follow recommended protocol suggestions. I understand it is my responsibility to inform LLHR LLC of any changes in my medical conditions. Missed therapy appointments will not be refunded or prorated. I understand I will incur $50 non-refundable cancellation fee unless cancelled within 48hrs.

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Date	Postal Code