Please fill out the consultation form and upload your photos.Our Certified Trichologist will then use this information to help her determine the cause and stage of your hair or scalp condition during your online consultation

Name*
Mobile*
Your Email*

Street Address*
Suburb*
State*

Post Code*
Date of Birth*

Is this your first time consulting with us?

YesNo

Do you have any history of illness such as

Liver diseasKidney failureDiabetesCushing's SyndromeAddison's DiseaseHypoglycemiaAnemiaAnorexia NervosaNone

Are you currently taking any of the following medication?

Anti-cholesterolemicAnti-coagulantsAnti-mitotic agentsAnti-ulcerantsBeta-blockersPsychotropicsRetinoidsAllopurinolDanazolInterferonLevodopaVitamin A, vitamin D or FosamaxNone

Have you used any other grey hair treatments in the past?

YesNo

What products have you used?" "How long did you use them for"?

Have you consulted another health professional before regarding your grey hair issue?
If so, did they say you have one of the following conditions:

Diffuse Hair LossMale Pattern Hair LossFemale Pattern Hair LossAlopecia AreataI haven't consulted anyone beforeOther

Do you have a family history of grey hair?

Father sideMother sideBrotherSisterNone

How many hours do you sleep usually?

Any other hair or scalp issue?

Experiencing a large amount of hair fallHair gradually getting thinnerPatchyItchy ScalpDandruff & FlakyOther

Duration Of Grey Hair Issue?

How often do you shampoo your hair?

Do you suffer from any other allergies? if so please

Do you /have you ever had an allergic reaction to alcohol

YesNO

Have you changed your diet recently?

YesNO

Are you vegetarian?

YesNO

How did you hear about us?

Friend referralFacebookGoolge/websiteWalk byOther

Name of friend, if friend referral:

Have you permed or straightened your hair before?

yesNO

How often:

Photo Taking Guide

"Please follow the photos below to take your own set of similar photos and then upload here".

Front Photo  Maximum file size for attachment is 5MB

Right Photo   Maximum file size for attachment is 5MB



Left Photo   Maximum file size for attachment is 5MB
Rear Photo   Maximum file size for attachment is 5MB


Note -: Please be sure to record the distance between your head and camera as you will need the exact same distance for your after photo comparison.

Any other comments?