Hair Loss Consultation

Before and after hair growth

Are you experiencing hair loss?

Whether it be thinning hair, a receding hairline, or baldness, we may be able to help.

Please take a few minutes to complete the questionnaire below. The more information you provide, the better we will be able to develop a solution to restore your healthy, beautiful hair.




May we email our news and specials to you? (required)
YesNo
We will not sell your information to any third parties.

Hair Condition

Do you have or have you ever had:

Breakage?

YesNo If yes, where?

Thinning?

YesNo If yes, where?

Bald Spots?

YesNo

If yes, which stage of baldness best shows your pattern?

I-1I-2I-3I-4FrontalII-1II-2IIIAdvanced
baldness scale

Dry itchy scalp?

YesNo If yes, where?

Dandruff?

YesNo

Adverse reaction to products, treatments, or chemicals used on your skin or scalp?

YesNo Please explain:

Hair Care History

Please select any of the following services you have received within the past year:

Chemical Relaxing or Straightening

Last Applied: How Often:

Perm

How Often:
Last Applied (approx):

Texturizing Treatment

How Often:
Last Applied (approx):

Highlighting or Lowlighting

How Often:
Last Applied (approx):

Full Color

How Often:
Last Applied (approx):

Do you currently have any of the following? Check all that apply:

Bond/glueBraidsHair Unit/Replacement WigInfusionInterlockMircrobraidsMicroringsSew-inOther
Please describe other:

How long will your current style last?

Hair Weave and Extension History

Are you currently wearing a weave or extensions?

Yes, continueNo, skip this section

What system are you currently using?

Are you satisfied with it?

YesNo, why not?
Please explain why not:

What is your natural hair texture?

CurlyKinkyWavy

Style Information

PermedStraightenedOther

How much time do you spend caring for your hair each day?

Describe your desired look. What about the look is most appealing to you?

How often do you shampoo and condition your hair?

Please list any hair care products you use on a regular basis:

How long have you used them?

Are you satisfied with your current products?

YesNo, why not?

Which of the following tools do you use to style your hair?

Blow dryerCurling ironFinger combingFlat ironRound brushOther, please list

How long is your natural hair currently?

Hair Length Chart

What is the current condition of your hairline/edges?

Full hairLoss hair/baldBreakageOther, please describe

Is there any other information which you think might be helpful that you would like to share

NoYes, please share

If you would like to upload a picture of your hair in its current condition, please do so here:

(50MB size limit)

Health History

Are you currently taking any prescribed medications?

YesNo
If yes, which ones?

Are you currently taking any vitamins or hormones?

YesNo
If so, which ones?
Have you ever been treated by a doctor for hair loss and/or scalp problems?YesNo
If yes, when were you last treated?