New Client Form

Birthday*

Please Select All Scalp Issues You'd Like to Address:*

Do You Have Family History of Hair Loss?*

Rate your progression of hair loss?*

How often do you shampoo your hair?*

How often do you blow dry or heat style your hair?*

How often do you use leave in styling products on your hair? (Gel, mousse, hairspray, etc.)*

Do You Get Perms?*

Do you bleach, dye, or chemically treat your hair?*

Rate Your Degree of Hair Damage:*

Are you on a GLP+1?*

Do you smoke?*

Do you drink caffeine?*

Do you drink alcohol?*

Do you exercise?*

How many hours of sleep do you get?*

Rate your stress level:*

What is your natural hair texture?*