Hair Growth Consultation Form

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Today's Date *

Which Challenge are you interested in? (Select One) *

First Name *

Address *

Last Name *

City *

Email *

State *

Occupation *

Zip *

Home Phone *

Cell Phone *

1. How long have you been losing hair? *

2. Where is your hair loss occurring? *

3. Is the scalp visible in the area of loss? *

4. Do you or have you used chemicals on your hair (relaxer, color, perm, etc.)? *

5. If so, when? *

6. Is your hair loss gradual or coming out quickly? *

7. Have you ever had your hair and scalp analyzed? *

8. Have you seen a doctor because of your hair loss? *

If yes, when? *

What was your diagnosis? *

What was recommended? *

What were your results? *

9. Have you tried other hair loss treatments? *

If so, what? *

What were your results? *

11. How often do you shampoo your hair? *

12. Please list name brand products of hair products you are using at home:

Shampoo: *

Other Products *

Conditioner: *

Hair Spray: *

Scalp Oil *

14. Have you ever lost your hair due to braids, weaving or wigs? *

If yes, when? *

15. Do you have any allergies? *

If yes, please list the types *

16. Are you taking any medications? *

17. Do you have any allergies? *

If yes, list medications: *

If yes, list allergies: *

18. Have you had any surgeries? Please list dates... *

19. Have you had blood work in the last 6 months (thyroid, ferritin-iron, hormones, vitamin D, CBC)? *

Were there any concerns or low levels? If so what? *

20. Is there a family history of hair loss (mother, father, sister, brother, grandparents, etc...)? *

If yes, who? and specify if they're from mom or dad's side... *

To serve you better, please upload images of area(s) of thinning or hair loss. Faces do not need to be shown. Be sure to take the picture at least 3 to 6 inches away.

Upload Photos *

Max file size: 20MB

Upload Photos *

Max file size: 20MB

Upload File *

Max file size: 20MB

I have a strict privacy policy. All files are kept safe from the public and will only be used for purposes of consulting about your hair problem and recommending treatments based on information given. My services are not to diagnose, cure or treat any diseases. Please see your medical practitioner if you have any medical issues.

Signature: *

Date: *

Upload Photos *

Max file size: 20MB

Upload Photos *

Max file size: 20MB

Upload File *

Max file size: 20MB