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

First name

Last name

Birthday

Month

Day

Year

Phone

Main Concerns

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

Shedding

Thinning

Bald spots

Breakage

Scalp irritation or inflammation

CCCA (if known)

Other (please explain)

When did you first notice changes in your hair?*

Have you been diagnosed with any type of alopecia? If so, which one ?*

Scalp & Styling History

Do you currently wear protective styles? (wigs, braids, weaves, etc.)*

Yes

Do you wear heavy oils and butters on your scalp or hair?*

Yes

Have you ever had chemical relaxers or permanent color? *

Yes

Are you currently experiencing itching, burning or scabbing on the scalp? *

Option 1

Option 2

Health & Wellness

Are you currently perimenopausal or menopausal ?*

Yes

Are you currently pregnant or postpartum ?*

Yes

Do you have any known hormonal imbalances? (PCOS, thyroid issues, etc.)*

Yes

Are you currently undergoing chemotherapy or radiation for cancer? *

Yes

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.

Please upload clear images of the areas of concern.*

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!

bottom of page