First Name

Last Name

Address

State

City

Postal code

Phone *

Email *

Date of birth

Age

Occupation

Lead Source

By providing my phone number, I agree to receive text messages from the business.

Taking medications for any of the following?

Anti-Coagulants
Anti-Hypertension
Hormones
Thyroid
Aspirin
Multivitamins
Radiation Therapy
Chemotherapy

Male Only - Click NEXT if Female

Do you have an enlarged prostate, prostate cancer?

Yes

Have you currently had or plan to take a PSA blood test for the screening of prostate cancer?

Yes

Have you ever been treated for or had breast cancer? *

Yes

If yes, when was your last Radiation / Chemotherapy treatment?

Have you been released from your Oncologist?

Yes

Oncologist Release Date

Are you a vegetarian?

Yes

How many daily servings of protein?

How many daily servings of vegetables?

How many daily servings of fruit?

How many daily servings of carbohydrates?

How many daily servings of caffeine?

Have you lost weight recently?

Yes

If so, how much weight have you lost?

Have you had Covid-19?

Yes

If yes, how long ago did you have Covid-19?

Did your hair loss start or get worse after you had Covid-19?

Consent for treatment

I agree to being evaluated and I understand I will first undergo a comprehensive preliminary evaluation by an experienced consultant. All other checkups are included with the cost of the program, which include monthly and/or quarterly digital and microscopic pictures, for which I give my consent. I further understand results will vary depending on a large number of factors. I acknowledge that it is my responsibility to the company of any changes in my condition, no matter how slight.

I understand some general recommendations will be made based on the initial consultation.

Signature

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Hair Rejuvenation Center