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Please fill out the appointment request and intake form below. Answer each question to the best of your knowledge and also let us know what your primary hair and/or scalp questions or concerns are. As soon as we receive your appointment request you will be contacted to confirm your appointment. 

Name*

Email Address*

Address*

City, State, Zip*

Phone Number*

Service Request*

Date Request*

Time Request*

Medical History: List Medications

High Blood Pressure*

Diabetes*

Thyroid Condition*

Heart Disease*

Allergies *

If yes list allergies

Vitamin Definciencies*

If yes, list vitamin(s) and levels if known

Hair Information: Check all that apply

Color

Hair Strands

Scalp

Scalp

hair shedding

List products being used

Any other concerns or questions

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