Trichology Consultation/Consent Form | Aesthetics Forms Portal

Trichology Consultation and Consent

Client Details

Full Name: *

Date of Birth: *

Contact Number: *

Email: *

Medical History

Do you have any medical conditions? *

Please list: *

Are you currently taking any medications? *

Please list: *

Do you have any allergies? *

Please list: *

Have you recently been unwell? *

Which of the following were you unwell with? *

Please provide detail: *

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone: *

Consultation

When did you first notice your hair loss?

What first made you aware of your hair loss?

In which areas are you experiencing hair loss?

Top of head only Top and sides of head (all over the scalp) At the front (receding hairline) At the back/vertex area Small patches in random areas Other

If Other, please specify:

Where is your hair loss most bothersome?

Approximately how much hair are you left with on the head?

Under 25% 25%-50% 50%-75% Over 75%

What bothers you most about your hair loss?

Have you already tried any of the following treatments/therapies? Please select all that apply.

Propecia Laser hair therapy Supplements Hair products Rogaine PRP Hair System Previous hair transplant surgery

What would be the best thing about having your hair back? Please select all that apply.

I’d look younger I’d feel more attractive I’d feel more confident I could style my hair the way I want Other

If Other, please specify:

Have you experienced any hair loss on your face?

If Yes, please give details:

Have you experienced any hair loss on other parts of the body?

If Yes, please give details:

Is there a history of hair loss in your family?

Hair/Scalp Care

How would you rate your general health and fitness?

Are you under pressure or stress?

Do you work in an environment that exposes you to chemicals on a daily basis?

Do you regularly plait or braid your hair?

Do you use extensions or a weave-on?

Do you use chemicals on your hair? (e.g. bleach, perm solutions, hair colourings, relaxers etc.)

How often do you wash your hair?

Is your scalp...

Flaky? Itchy? Dry? Oily? Normal? Prone to dandruff?

Does your scalp weep?

Is there a crust build up on your scalp?

Please use this box for any additional notes/comments in regards to your skin/scalp's condition:

Diet

Do you follow a specific diet? (e.g. Vegan, Pescatarian, Vegetarian etc.)

Do you take any mineral or vitamin supplements?

Please specify:

Has your weight changed dramatically in the last 12 months?

Please specify whether you have lost or gained weight, and approximately how much:

Photos

If possible, please upload clear photos of your hair loss to help us be better prepared for your appointment.

Top

Front

Back

Side Left

Side Right

Consent

I accept that any treatment I am going to receive is at my own risk.

I certify that I have read, fully understood, and completed this form to the best of my knowledge.

I understand that failure to disclose information requested above may result in adverse side effect(s), unknown because of this to which I accept full liability/responsibility.

The treatment(s) and possible side effect(s) have been fully explained to me.

I accept full responsibility for the treatment given and complications which may arise or result during or following any procedure that is performed at my request.

I accept that if I am not satisfied with the treatment I will inform the therapist and/or request to speak to the manager during, or immediately following, the treatment.

I fully understand the above and consent to the Trichology treatment(s) to be carried out.

Client Signature: *

Tap or click on the signature above to sign