CONFIDENTIAL Hair Loss/Restoration Consultation Questionnaire

    Please fill out as accurately as possible and completely, so I can better serve your needs.  Thank you.

    ​Briefly give us your background story of hair loss symptoms and experience

    Medical History

    Females Only

    Males Only

    NUTRITION
    CONDITIONS OF THE SCALP
    If yes, in each box below, list your medication, symptom/diagnosis & how long you've been taking medication.
    HEREDITARY
    RELATIVES
    What are your goals and expectations? 
    Max file size: 20MB
    Max file size: 20MB
    Max file size: 20MB
    Max file size: 20MB
    Consent for Treatment 
    I am being evaluated by Blessings Beauty and Hair Restoration Center and understand I will first undergo a comprehensive preliminary evaluation by an experienced hair loss consultant.  This preliminary evaluation will include a complete and thorough medical and hair loss questionnaire, a scalp evaluation if available which includes standard medical photography (no face shown), and microscopic photography for which I give consent.  I also understand that although Blessings Beauty and Hair Restoration Center has had many very successful clients, each client is different and like any medical or cosmetic treatment, results will vary depending on a large number of factors.  I acknowledge it is my responsibility to inform Blessings Beauty and Hair Restoration Center of any changes in my medical condition no matter how slight and agree to read all product labels and treatment information provided to me so I can understand my treatments and get the best possible results.

    I understand some general recommendations will be made based on the initial consultation.