Consult form | Hair Loss Clinic

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Welcome. Let’s make sure this is the right next step for you.

This short form helps me understand where you are in your hair loss journey and make sure I’m offering the right support.

Please note:

• A $75 deposit is required to secure your consultation. The remaining $75 and the price of the recommended products is due at your appointment.

• During your session, you’ll receive a personalized treatment plan and product recommendations tailored to your needs.

• Product bundles range from $153–$550 for a 3-month supply, depending on your goals and stage of hair loss.

If you’re in the beginning to moderate stages of hair loss and ready to take action, let’s get started.

First name*

Last name*

Email*

Phone*

Birthday (This helps assess age-related hormonal factors)*

Month

Day

Year

How long have you been experiencing hair loss?*

Less than 6 months

6-12 months

1-3 years

Over 3 years

Where are you noticing hair loss? (Check all that apply)*

Hairline

Crown

Overall thinning

Bald spots or patches

Other

Do you have visible scalp or is the area mostly bald?*

Some thinning

Moderate thinning with visible scalp

Large bald spots

Completely bald in some ares

Have you tried any treatments before? *

Yes

If yes, what treatments have you tried?*

Upload a photo or video (optional but recommended)

A photo f the area of concern helps me better assess your stage of hair loss.

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