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Consultation Form

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Customer Information

Section 1 of 5

Personal Information

Age

Occupation

Emergency Contact Name

Emergency Contact Phone

Medical History

Do you have any of the following medical conditions?

Diabetes

Heart/Organ Conditions

Blood Disorder

Skin Condition

Allergies

Other

None of the above

Please provide more information about your condition(s) *

Are you currently taking any medications?

Yes

Please provide details about your medications *

Previous Hair Loss Treatments

Treatment Information

Expectations & Lifestyle

What are your expectations from this treatment?

Lifestyle Factors

How did you hear about us?

Google Search

Social Media

Friend Referral

Other

Photos & Documentation

Upload Photos (Optional)

Upload photos of the area to be treated. This helps us provide more accurate consultation. Maximum 5 photos, 10MB each.

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Click to select photos or drag & drop

JPEG, PNG, or WebP (Max 10MB)

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Consent & Agreement

Additional Information

I consent to receive the selected treatment and understand the risks involved

I consent to photos being taken for treatment planning and marketing purposes

I have read and agree to the Terms & Conditions and Privacy Policy

I would like to receive marketing communications about treatments, offers, and health tips (Optional - you can change this anytime in your customer portal)

Section 1 of 5

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Thank you for completing your consultation form. Our team will review your information and contact you soon to schedule your appointment.

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