Client Intake

New Client Intake Packet

Step 1 of 4: New Client Info

New Client Questionnaire

Full Name *

Date of Birth

Phone Number

Email Address *

How did you hear about us?

I consent to receive follow-up emails about my intake and treatment.

I consent to receive follow-up text messages (SMS) about my intake and treatment.

Have you seen a trichologist or scalp specialist before?

Primary Concern

How long have you had this concern?

Any diagnosed scalp or skin conditions?

Health Conditions (check all that apply)

Diabetes

Hypertension

Thyroid disorder

Lupus

Alopecia Areata

Psoriasis

Eczema

Seborrheic Dermatitis

Iron deficiency / Anemia

Autoimmune condition

Cancer / Chemotherapy

Hormonal imbalance

Other

Current Medications

Known Allergies

Current Scalp/Hair Products Used

Diet & Water Intake

Stress Level

Sleep Quality

Goal for This Program