Hair Loss Consultation
Extensions Consultation
Hair Styling Appointment
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Hair Loss Consultation
Hair Extensions Consultation
Hair Styling Appointment
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Hair Loss Consultation
Hair Loss Consultation Request Form
First Name *:
Last Name *:
Address *:
City *:
Phone number *:
Email *:
1. What are your expectations from us at Capilia by Caralyn* ?
Stop your hair loss
Have more hair
Treat a specific problem
Additional comments:
2. How would you describe your current hair loss?
10-20 hairs per day
21-40 hairs per day
41-99 hairs per day
More than 100 hairs per day
3. Have you seen a physician about your hair loss?
Yes
No
4. Are you on a hair treatment program *?
Yes
No
If yes what program and what have been the results?
5. Do you consider you hair to be...
(please select)
Oily
Dry
6. On a scale from 1 to 10 rate the urgency of your hair loss
(
10
being most urgent)
1
2
3
4
5
6
7
8
9
10
For security reasons please put in letters and numbers shown above:
