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

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

YesNo

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

Are you currently taking any of the following medication?

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

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

Diffuse Hair LossMale Pattern Hair LossFemale Pattern Hair LossAlopecia AreataOther

Do you have family history of hair loss?

Father sideMother sideBrotherSisterNone

How many hours do you sleep usually?

What is your main concern

Experiencing a large amount of hair fallHair gradually getting thinnerPatchyGrey hairItchy ScalpDandruff & Flaky

Duration of Hair loss?

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:

Must see the whole thinning area of scalp. Separate the hair from the center with a comb, making a part in the middle and focus the camera shot on most affected area of the scalp.

Front Photo  Maximum file size for attachment is 5MB

Lift hair up near the temple with opposite hand to show the thinning area of the temple then look up. Focus the camera shot on most affected area.


Right Photo   Maximum file size for attachment is 5MB


Lift hair up near the temple with opposite hand to show the thinning area of the temple then look up. Focus the camera shot on most affected area.


Left Photo   Maximum file size for attachment is 5MB

Must see the whole thinning area of scalp, directly behind subject. Separate the hair from the center, making a part in the middle and focus the camera shot on most affected area.

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?