Consultation Form Name(Required) Phone(Required) Address(Required)Occupation(Required) Date of Birth MM slash DD slash YYYY Age Gender Special Interests Physical Fitness Sports Travel How often would you attend training, gym or other physical activity per week(Required) How long have you been suffering from hair loss?(Required) Has it happened suddenly and are using losing much hair?(Required) Do you have any relatives that suffer from hair loss?(Required) Yes No Have you used any treatments for hair loss? Yes No Please specify treatment used(Required) Have you ever had an allergic reaction to treatments?(Required) A Patch Test is required for all relevant treatmentsHave you any medical conditions?(Required) Yes No Please explain you medical conditions(Required) Current/Recent Medications(Required) I declare the above information to be true, knowing my provider relies on this information to provide safe and effective treatment(Required) I consent to the above statement Ticking the above box is the equivalent of a digital signature Robot check done automatically
