Let’s Have a Real Conversation

Name

Email Address

Age

Gender Gender Male Female

What is the texture of your hair? What is the texture of your hair? Straight Wavy Curly Kinky-Curly

Hair Condition: Hair Condition: Chemically Treated Color Treated Natural

What is your stress level? What is your stress level? High Normal Mild None

Please list your medications.

Have you undergone any treatments that list hair loss as a side effect? Have you undergone any treatments that list hair loss as a side effect? Yes No

Have you been placed under anesthesia within the last 6 months? Have you been placed under anesthesia within the last 6 months? Yes No

Do you have any known allergies? If yes, please list them

What hair products do you currently use? How long have you used this product?

Please describe the problems you are having with your hair & scalp.