Please complete our Client Consultation Form ahead of your appointment

Client Consultation Form

Personal Information

First name

Last name

Birthday

Day

Month

Year

Mobile Number

Other phone number

Surgery Address

Next Of Kin

Next Of Kin Contact Number

Next Of Kin Address

Hair Type and Condition

How would you describe your hair?

My hair is:

Hair Length:

Please provide us with a image of your current hair

Hair History

Have you ever suffered from hair loss?

Have you ever been diagnosed with Alopecia?

Do you Currently take any medication?

If Yes, Please state which medication:

Do you suffer with Psoriasis of the scalp?

Do you have any known allergies?

Are you currently pregnant or have you been pregnant in the last 6 month?

Do you currently colour your hair?

If yes, how often?

If yes, please let us know if this is done professionally?

Have you had your hair permed of chemically straightened in the last 12 months?

If Yes, How long ago?

Lifestyle

Do you frequently swim or go to the gym?

Are you going on holiday to a hot country in the next 6 weeks?

If Yes, please state how long until your holiday?

Contact

If you are happy for us to contact you, please select which channels you would prefer?

Text

Call

Signature

Signature field is empty.

I confirm that the information provided above is True and accurate at the time of filling out this form.

Please complete our Client Consultation Form ahead of your appointment

Client Consultation Form

VISIT
US

104a Stockton Road
Hartlepool
TS25 1RP

CONTACT
US

T 01429 247140
M 07887 090824

Find Us On
Facebook & Watsapp

TELL
US

Please complete our Client Consultation Form ahead of your appointment

Client Consultation Form

VISIT US

104a Stockton Road Hartlepool TS25 1RP

​

CONTACT US

T 01429 247140 M 07887 090824 Find Us On Facebook & Watsapp​

TELL US

VISIT
US

104a Stockton Road
Hartlepool
TS25 1RP

CONTACT
US

T 01429 247140
M 07887 090824

Find Us On
Facebook & Watsapp

TELL
US