TricHolistic Intake

Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Birthdate*

MonthDayYear
Date
Which of our services are you interested in?

Hair RestorationHealth and WellnessFinancial Wealth
At what age did you notice hair loss and how long have you been experiencing hair loss?*
How did you hear about us?

Existing ClientRadioOnline searchDr. referralStylist/SalonOther
What do you hope to achieve during your consultation?*
For hair restoration, please upload NO MORE THAN (5) IMAGE photos. (left, right, top of head, back of head)*

Please include any areas of concern you would like to discuss
Cancelof
Status

MarriedSingleRecently Divorced (3yrs or less)Domestic violence (current or prior)
If you could restore your hair today, what financial investment is comfortable for you?*

$1000-$2000-Base$2000-$4000-Mid grade$4000-$6000-ComprehesiveTop of the line please
We ask the financial decision maker be present during the consulation. Are you the financial decision maker?*
Which payment option works best for you*

Out of pocketCarecreditHSA/FSA
Hair Conditions

ThinningBreakageTemplesCrownAll overWigs or weavesNatural no relaxer
Scalp conditions

Dry/ itchyOilyCrawling burining sensationRedenning/pain
Have you received Covid vaccination*
Have you experienced any of the following post vaccination*

Foggy brainDaily aches and pains from prior injuriesIrregular mensesDifficulty rememberingAnxietyDecreased Will to liveIncreased worryYes I test regularlyWish more people would wear their masksGet my regular booster shotsNone of the aboveOther
Did something trigger your health
What areas of stress do you have in your life*

WorkChildrenFamilyFinancesHealthEducationCareer ChoiceRelationshipPhyscial Activity
Any unusual stress or recent life changes
What makes you feel better
What positive changes are you making in your life
What are your stress relievers
Is the hair loss getting worse*
Do you have a professional stylist? His or her name?
Is your hair color temporary or permanent
Do you have breakage? What do you feel caused the breakage?
Other hair loss options I have already tried
Are you open to all natural plant based medicine for therapy
Do you sleep with the TV*
What EMF devices do you own*

Smart TvSmart refrigeratorRing house monitorAlexa or similiarOther
Any allergies to*

CopperNickelNeodymium magnetsYes, I have a pacemakerNone of the above
HAIR SAMPLE-PLEASE SEND 2-3 STRAND OF YOUR HAIR FOR ANALYSIS PRIOR TO YOUR APPT IN A "CLEAR" ZIPLOCK BAG. BE SURE TO INCLUDE YOUR NAME AND DATE OF YOUR APPT ON THE ZIPLOCK.

SHIP TO: MCBRIDE HAIR RESTORATION LLC, P.O. BOX 203, SIMSBURY CT 05070
I will ship hair sample prior to my appt*

YesNoOther
Health Education

Healing is within!
If you are monitoring your levels, hear what others say
- Dr. John Bergman. Pharma controls you. https://youtu.be/rv1zD5PAiQg
- Dr. John Bergman. Blood pressure and cholesterol. https://youtu.be/PXe2xldWxtY
- Dr. Peter Glidden. 3rd leading cause of death. https://youtu.be/xNVs_ClVw7U
- Dr. Brook Goldner. Lupus lecture. https://youtu.be/8NTgD8c9glM
- Dr. Bruce Lipton. Heal yourself. https://youtu.be/1dyqHr2letc
- Clay Morris. Covid coverup. Did our loved ones live longer or expire sooner. https://youtu.be/ERvURcpg3JE
Disclaimer and Release

Health and Model release
I understand MHR LLC does not claim to heal, treat, cure, or diagnose any medical condition. I understand MHR LLC is not claiming to be a medical office, clinic, or medical professional. Any information gathered or conversation shared is solely for the purposes of suggestions and/or recommendations of my own free will. I am encouraged to seek medical advise for any the suggestions, recommendations, and especially for any serious or life threatening diseases, disorders, and/or conditions.

I give consent for MHR LLC to use my case study, images, photos, and likeness for training and promotional purposes without compensation of any kind.
Signature*

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HAIR SAMPLE-PLEASE SEND 2-3 STRAND OF YOUR HAIR FOR ANALYSIS PRIOR TO YOUR APPT IN A "CLEAR" ZIPLOCK BAG. BE SURE TO INCLUDE YOUR NAME AND DATE OF YOUR APPT ON THE ZIPLOCK.

Health Education

Disclaimer and Release