Basic Client Information
First Name
Last Name
Email
*
Phone
*
Date of birth
Background & Lifestyle
Have you experienced any significant hair loss in the recently?
Where do you part your hair?
Do you switch your part or always keep it in the same place?
Switch it up
Always in the same place
Are you currently experiencing any abnormal shedding or hair loss?
Yes
No
What is the personal or professional opinion as to why this may be?
Approximately what is the longest your hair will grow by itself?
How do you usually style your hair?
Pony Tails
High Buns
Half Up, Half Down
Braids
All Down
Curled
Straight
What hair care products do you currently use at home?
Have you had any chemical services performed to your hair in the last 6-12 months?
Yes
No
What chemical services have you had in the last 6-12 months?
Health
Have you had any kind of surgery in the last 6-12 months?
Yes
No
Are you planning to have any kind of surgery in the next 6-12 months?
Yes
No
Do you use any deep conditioners or oils on your scalp?
Yes
No
Are you pregnant or planning to get pregnant?
Yes
No
Are you currently taking any supplements or medications?
Yes
No
What supplements or medications are you currently taking?
Additional Consultation Notes
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