Clinic Intake

Full Name

First NameLast Name

Phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth

Date

Occupation

E-mail

Who referred you?

Medical History

Allergies

General Health

Previous surgery with General Anesthesia

Do you have any of the following medical problems?

Presently Undergoing Medical Treatment for

Stress

Medications

Please list name of medications and dosage

Females Only

If "yes" how long have you taken Contraceptive Pills?

Males Only

Nutrition

How many daily servings of protein do you get?

How many daily servings of fruit do you get?

How many daily servings of vegetables do you get?

How many daily servings of caffeine do you get?

How many daily servings of carbohydrates do you get?

Have you lost weight recently?

If you've lost weight recently, how much?

Conditions of Hair & Scalp

What type of scalp do you have?

Area(s) of hair loss?

If you have experienced hair loss on your body, where?

What age did you notice your hair loss?

Was your hair loss Sudden or Gradual?

How many hairs lost per day?

What type of shampoo are you currently using?

What type of conditioner are you currently using?

How many times per week do your shampoo?

What tempature is you hair dryer set on typically?

Is your hair loss concern caused by any medical problems or medications that you are aware of?

Heredity

Who in your family has experienced hair loss?

What opinions have you researched for your hair loss (Including over the counter and prescriptions?)

Does your hair loss bother you?

What are your goals and expectations?

Please indicate where hair loss bothers you the most.

Other details you may wish to highlight

Consent of Treatment

I am being evaulated at Vitalize Ambiance Hair Loss & Restoration Clinic and understand I will first undergo a comprehensive preliminary evaluation by one of our experienced Trichologist. This evaluation will determine if I am a suitable candidate and I understand that the cost of the initial evulation is 150$. All other follow up appointments are included with my hair restoration program. This preliminary evaluation will include a complete and thorough hair and scalp analysis, questionnaire and scalp evaluation including standard photography (no face seen), and microscopic photography. Further evaluation will consist of monthly or quarterly digital and capilloscope pictures for which I give my consent for all the above. I further understand that each person is different and like any treatment, my results will vary depending on a large number of factors. I acknowledge that it is my responsibiity to infom the company of any changes in my condition; no matter how slight.

Signature

My Products

Consultation $150.00

Total $0.00

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Rows	Bald Hair	Thinning Hair	Not Bald Hair	Unknown
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