Hair Consultation Form

What is your current hair length?*

How would you describe your scalp?*

How would you describe the current condition of your hair?*

How would you describe the natural texture of your hair? *

How would you describe the density of your hair? *

Are you currently taking any medication that has side effects that can cause hair thinning and/or hair loss?*

Do you have now, or have had in the past, any problems with hair loss? *

Do you have problem with dandruff?*

Would you like to send a current [close-up] picture of your hair? *

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I understand that the above information will be kept confidential and is accurate to the best of my knowledge.

Your Company Name