Confidential consultation questionnaire

At Advanced Hair Studio your hair is our responsibility. We request that you complete this form as candidly and honestly as possible in order that our hair loss consultants and practitioners can give you the best possible advice and guidance.

First Name *:

Middle Name :

Last Name *:

Full Address :

Phone No.(Home) :

Phone No.(Business) :

Phone No.(Mobile) *:

Email *:

Date of Birth :

Occupation (Please Specify) :

Preferred language :

Please specify working conditions, special interests or hobbies that you think might affect hair replacement :

Do you know any existing client of Advanced Hair Studio :

Name

Procedure Done

How long have you been losing your hair?

Have you consulted any doctors / clinics?

if yes, please specify :

In hair replacement, which other organisations do you know?

What have you previously tried to counter hair loss?

Nothing

Hairpiece

Tablets (specify)

Laser Therapy

Lotions (specify)

Surgical procedures

Shampoos (specify)

Was the treatment effective (if any)?

Please list any health concerns / conditions / allergies or medications you are currently taking :

What are your expectations from the treatment:

I want a head full of hair with density, coverage and volume (hair to play with, hair to style)
Coverage of bald areas
Specific area to be addressed

Please specify (Which Newspaper / Magazine / TV channel / Mall / Salon / Doctor etc) :

Would you be excited if a professional company ensures your hair style is always matching the world's latest trends according to your age group, profession and expectations?

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