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Hair Replacement Consultation Form
Please complete this form if you are interested in our hair replacement services. We will get back to you within 1-2 days business days with a scheduled in-person consultation.
*This is a detailed consultation form to give us some insight on how we can better serve you. This questionnaire will take about 15 minutes to complete, please answer all questions to the best of your ability.
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Date
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Name
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First
Last
Address
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Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Phone
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Email
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Emergency Contact Name
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Emergency contact #
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D.O.B
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MM
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Occupation
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How did you hear about TruBeauty?
*
Google
Social Media
Word Of Mouth
Other
Relationship Status
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Single
Married
Divorced
Separated
Widowed
How would you prefer to be contacted?
Text
Call
Email
What time should we contact you?
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Morning 8-10am
Afternoon 12-3pm
Evening 5-8pm
Anytime
What are the days and times you are available?
*
ABOUT YOUR HAIR LOSS JOURNEY
What type of hair replacement are you interested in discussing? Please check all that apply; keep in mind that every hair loss solution is not applicable for every client.
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Hair Topper
Cranial Prosthestic/Wig
Hair Intergration
Not Sure
Is permanent hair loss hereditary in your family?
*
Please select
YES
NO
I DON'T KNOW
Age when you noticed hair loss:
*
Pregnancy or childbirth within last 12 months?
*
Please select
YES
NO
Have you ever been treated for a hair and /or scalp problem? If yes, when and by whom?
*
Are you presently taking any medications? If yes, please list
*
What other hair replacement alternatives or hair loss options have you considered?
*
Have you had a hair addition before?
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Please select
YES
NO
Do you wear a hair addition now? If yes, provide details.
*
What activities or hobbies do you participate in reguarly?
*
Baseball
BasketBall
Biking
Gym Cardio
Tennis
Running
Yoga
Swimming
Other
Indicate which areas your hair loss affects you (check all that apply):
*
Meeting new people
Outside on a windy day
Wearing hats
Dating
Sitting in front of people
Your self-esteem
Swimming or hanging at the beach day
Seeing old friends
Intimacy with significant other
What is your main goal?
*
Stop hair loss
Fill in areas where you have hair loss
Have a full normal head of hair
Other
If you have been advised by other professionals, why have you chosen TruBeauty?
Dissatified with previous advice or results
Reputation and experience
Location
Are you generally in good health?
*
Please select
YES
NO
Are you under a doctor's care?
*
Please select
YES
NO
Third option
Have you had prior hair transplants?
*
Please select
YES
NO
Check any of the following that you currently or have ever had:
*
Heart Disease
Kidney Disease
Convulsions
Dizziness
Hives
High Blood Pressure
Lung Disease
Venereal Disease
Hay Fever
Eczema
Liver Disease
Fainting Spells
Diabetes
Asthma
Ringworm
None
Do cuts on your skin heal normally?
*
Please select
YES
NO
Do you have tendency toward keloids? (raised ridged scars)
*
Please select
YES
NO
Have you had any allergic response or adverse reactions to substances put onto your skin?
*
Please select
YES
NO
Do you take large amounts of aspirin? (more than normal)
Please select
YES
NO
Are you allergic to latex?
*
Please select
YES
NO
Have you had any allergic response of adverse reactions to any drugs or medications?
*
Please select
YES
NO
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