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First name
Last name
Email
Phone
*
What is your primary hair concern right now?
I want a new style, cut, color, extensions, silk press, etc.
My hair is breaking, thinning, shedding or not growing as expected.
I have scalp concerns such as itching, flaking, irritation, or excessive oiliness.
Im experiencing multiple hair/scalp concerns
*
Are you experiencing noticeable hair shedding?
No
A little more than usual
Yes, significantly
Im not sure what is normal for me
*
Have you noticed areas of thinning or visible scalp that weren't noticeable before?
No
Slightly
Yes
Im not sure
*
Are you experiencing excessive breakage?
No
Yes, but I know what may be causing it (styling, chemicals, heat, etc)
Yes and I dont know why
My hair is breaking and thinning
How would you describe your scalp?
Healthy with no concerns
Dry or tight
Flaky or excessively oily
Itchy, irritated, tender or painful
I have bumps, sores, crusting or other noticeable changes
Other
*
Have you experienced a change in your hair within the last 6-12 months?
No
More shedding
Thinning
Changes in texture or density
My hair/scalp just doesn't seem the same
*
Have you recently experienced anything that could affect your hair or scalp?
Major stress
Illness or surgery
Significant weight change
Pregnancy/postpartum changes
Medication or supplement changes
Dietary/nutritional changes
None that im aware of
*
What are you hoping to accomplish?
Maintain healthy hair?
Achieve a specific hairstyle
Improve my hair's strength/condition
Understand why my hair is shedding or thinning
Improve my scalp health
Create a personalized hair/scalp wellness plan
*
Have you tried products, treatments or lifestyle changes to address your concern?
No
Yes and it improved
Yes, but the concern continues
Ive tried several things without understanding the root cause
*
Which statement sound most like you?
My hair is healthy. I mainly need styling and maintenance
My hair needs help, but im not experiencing a major scalp or hairless concern.
Something has changed with my hair and/or scalp and I want to understand why.
Im experiencing hair loss, thinning, excessive shedding or a scalp concern and need a professional assessment.
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