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Woman's Hair Loss Consultation Form (Pre-Booking)

Birthday
Month
Day
Year

Main Concerns

What are your current hair/scalp concerns? (Check all that apply)

Scalp & Styling History

Do you currently wear protective styles? (wigs, braids, weaves, etc.)
Yes
No
Do you wear heavy oils and butters on your scalp or hair?
Yes
No
Have you ever had chemical relaxers or permanent color?
Yes
No
Are you currently experiencing itching, burning or scabbing on the scalp?
Option 1
Option 2

Health & Wellness

Are you currently perimenopausal or menopausal ?
Yes
No
Are you currently pregnant or postpartum ?
Yes
No
Do you have any known hormonal imbalances? (PCOS, thyroid issues, etc.)
Yes
No
Are you currently undergoing chemotherapy or radiation for cancer?
Yes
No

Please Note: If you are currently in active cancer treatment, I am unable to begin hair restoration services at this time. I'd be honored to support you once your trreatment has been completed and you've received medical clearance.

After you submit this form you'll be redirected to book a consultation and pay a 50% non-fundable deposit. The cost of the consultation is $320. Thank you and I look forward to servicing you!

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