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THANK YOU FOR SHOPPING WITH LAURENS HAIRTIQUE
Client Hair Loss Intake Questionnaire
Thank you for your interest in booking with Lauren's Hairtique please take the time to fill out the intake form
below. Once completed, go to the booking tab and schedule the consultation of your choice.
Full Name
How old were you when you first noticed your hair loss?
Is there a history of hair loss in your family? If so, list in detail.
Select any of the following that you’ve had or currently have.
Heart Disease
High Blood Pressure
Liver Disease
Kidney disease
Cancer
Diabetes
Asthma
Hives
Eczema
Thyroid disease
Psoriasis
Blood disorder
Are you on any medications? YES or NO, If yes please list. (I understand this may be a little intrusive but it is very important to the starting and progression of your hair loss. Together we can possibly determine a more holistic approach to many of your medical problems.
What activities or hobbies do you participate in regularly? Indicate below.
Do cuts on your skin heal normally?
Choose an option
Have you been put under any anesthesia within the last 6 months? Have you given birth within the last year? YES or NO. If so did you breastfeed and when did you stop or are you actively in menopause or pre-menopausal?
Do you have any known skin or shellfish allergies?
Submit
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