Rekindle Consultation Request Form

Client Intake Form

All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.

Name

First NameLast Name

This is my:*

Phone Number*

E-mail*

Occupation

Age

Hairloss/Thinning

What are you experiencing:

Where? When did it start?

1. What is your hair goals and expectations?

How are you losing your hair

Was there anything happening in your life at that time you feel may have caused or contributed to your hairloss/thinning?

How would you rate your stress level

Do any of the following medical conditions apply?

6. Have you had surgery with General Anesthesia within the last 3 to 6 months

YesNoOther

If yes, when?

Are you currently or recently been under a physician’s care? If yes, please explain:

Are you Pregnant or given birth within the last year?

Are you Pre-Menopausal:

Are you Post-Menopausal:

Are you currently taking contraceptive pills

Have you recently lost weight?

If yes, please explain:

Have you recently gained weight?

If yes, please explain:

Have you ever been diagnosed with

Do you experience any of these symptoms in your scalp:

When would you like to schedule your in-person consultation?*

MonthDayYear

Disclaimer - The goal of this treatment program is to help assist and accelerate natural hair growth. Under certain medical scalp disorder conditions, this treatment program should not be performed.

I affirm that I have stated my known medical conditions, and answered all questions correctly. I understand that there shall be no liability to Rekindle Hair Restoration Solutions Hair Salon and/or the Certified Hair Loss Practitioner/ Hair Stylist performing the treatment should I fail to provide accurate information anytime during the six weeks or 12 weeks of this treatment program. I understand that this consultation form and treatment program is not a substitute for a medical examination, diagnosis, or treatment. I understand that Rekindle Hair Restoration Solutions Hair Salon and/or the Certified Hair Loss Practitioner/ Hair Stylist(s) are not qualified to perform, diagnose, prescribe, or treat any physical or mental illness, and that none of the information stated in the course of this consultation should be construed as such.

I understand that the information herein is for evaluation purposes and to aid in giving a customized treatment for the absolute best result and is completely confidential.

By signing this consultation form, I understand and agree to the information contained within.

Signature*

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