First Name *

Last Name *

Phone *

Email *

Hair Conditions (check all that apply) *

I twirl/twist/pull my hair/eyebrows

I have hair indi!erent lengths

I have hair thinning at my temple

I am thinning on the top of my head

My pony tail is getting smaller/shorter

I wear extensions/weaves/hair pieces

If you could restore your hair today, which "nancial investment is most comfortable for you? *

$2000-$4000

$4000-$6000

$6000-$8000

Which payment options is best for you? (check all that apply) *

In Full

HSA/FSA

3 monthly payments

Carecredit

Do you need someone other than yourself to make a "nancial decision to begin your Hair/Scalp Treatment Program? If so, we ask that they are present during your appointment *

Yes

No

Kindly read carefully:

Be sure to remove any weaves, braids, or other hair augmentations prior to your appointment that will prevent the Trichologist from getting to your scalp. (If any of these are not removed prior to your appointment, you will be charged the full consultation fee and you can reschedule your appointment for the next available opening.)

To AGREE to this policy check box to continue *

I agree