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My Hair Growth Clinic

Consultation Questionnaire

Birthday
Month
Day
Year

Personal History

Do you have any of the following issues? (check all that apply)

Females only:

Do you have Female Issues?
Yes
No
Postmenopausal?
Yes
No
Pregnant or Breastfeeding?
Yes
No

Males Only

Have you currently had or plan to take a PSA blood test for the screening of prostate cancer?
Yes
No
Do you have an enlarged prostate or prostate cancer?
Yes
No


Hair & Scalp Conditions

My scalp is usually: (check all that apply)
Do you pull on your hair?
Yes
No
Areas of thinning or hair loss:
Do you have hair of different lengths? (other than your layers)
Yes
No
Any hair loss on body?
Yes
No
Your thinning/hair loss was:
If you use a hair dyer, what heat do you use it at?
Who in your family has had hair loss or thinning?
How much does your hair loss/thinning bother you?
What are your goals and expectations?
Knowing that treatment options may take 6 months to show success, are you willing to wait that long?
Yes
No

Consent for Treatment

I agree to be evaluated and I understand I will first undergo a comprehensive preliminary evaluation by an experience consultant. All other check ups are included with the programs cost, which includes monthly and or quarterly digital and microscopic pictures, for which I give my consent. I further understand results will vary depending on a large number of factors. I acknowledge that it is my responsibility to the company for any changes in my condition no matter how slight. 

Date
Month
Day
Year

What's next? Click the link below if you have not booked your Consultation yet!

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