Confidential Questionnaire
 

Name:

Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Email:

How did you hear about us and when?

Are you experiencing any medical problems that are contributing to your hair loss?:

 yes  no

If yes, please explain:

Does anyone else in your family suffer from hair loss?:

 yes  no

If yes, what is the relationship?:

Where is your hair loss?:

 top      front      sides      back      all over

What is your hair color?:

Are you happy with your hair color?:

 yes  no

Do you want highlights?:

 yes  no

If yes, what color?:

Do you want any style changes?:

 yes  no

If yes, please explain:

What type of volume/enhancement are
you hoping to achieve?:

Do you have any special events coming up?:

 yes  no     date:

Comments: