| Consultation Form |
| Information Requested |
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| First Name | |
| Last Name | |
| Address | |
| Address | |
| City | |
| State | |
| Zip | |
| Email | |
| Phone | |
| Date of Birth | |
| How long have you been losing your hair? |
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| Where has your hair loss occured? |
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| Is the scalp visible in the area of hair loss? |
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| Would you categorize your existing hair as.. |
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| Does your scalp excreet excessive sebum (oil)? |
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| Is the hair growing on the sides of your head? (choose one) |
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| Would you rate your current rate of hair loss? (choose one) |
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| Have you experienced any increase in your rate of hair loss this past year? |
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| Have you ever tried to do anything about your hair loss? |
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| Have you ever seen a doctor about your hair loss? |
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| Has anyone ever mentioned your hair loss to you? |
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| Does this bother you? |
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| Why do you want to do something about your hair loss? |
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| Do you want to ? |
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| Comments |
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