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Consultation Intake Form
Contact Information
Name, address, number & email address
Client Assessment
Please provide the following information
Shampoo, Conditioner & Additional Products used
Hair & Scalp Condition
Are you experiencing excessive hair loss or scalp issues. Please describe
Health History
Are you on medication, oral contraceptive, or have any other health issues
Hair History
How long have you been experiencing the hair loss or scalp issue. Can you email me a picture of the area of hair loss
Additional information
Please email all information to the following email address provided below