Consultation Questionnaire Gender * Name *
Address * Referred by Personal History Allergies * Are You Allergic to Shellfish? * General Health * Are you presently undergoing chemo or radiation therapy? * Stress Level *
(Please check with your physician to confirm, if any of your medications would have adverse affects with our product supplements or low level light devices)
Women Only Female Issues Post Menopasal Getting pregnant in the next 6mos.? Are you currently pregnant or nursing? Do you take Contraceptive Pills? Men Only Do you take Contraceptive Pills?Have you currently had or plan to take a PSA blood test? Do you have an enlarged prostate, prostate cancer? Nutrition Are you a Vegan? Loss weight recently? HAIR & SCALP Condition(s) Is your Scalp: *
Any Redness or itchy scalp? * Do you pull your hair? * Any Bumps or raised areas? * Recurrent attacks of patchy loss? * Hair of different lengths? * Areas of concern? * Do you have an areas of concern with thinning or aging hair on your body? * Frequency * Is your thinning hair getting worse? * Do you use a hair dryer? What temperature? When hair is wet, do you use a towel to rub dry? Do you color your hair? Is your thinning hair caused by any medical problems or medications that you are aware of? Does thinning hair run in your family? Parents Grandparents Siblings Aunts Uncles What options have you researched for your hair (Including over the counter and prescriptions)?
Select all that apply
How much does your thinning hair bother you? Did you tell anyone you were coming here today? What are your goals and expectations? * Knowing that treatment and/or surgical options may take 6 months or more to show success, are you willing to wait that long? * Please indicate which concerns bother you the most. *
Select all that apply
Consent for Cosmetic Services
I agree to being evaluated and I understand I will first undergo a comprehensive preliminary consultation 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 inform the company of any changes in my condition, no matter how slight.
I understand some general cosmetic recommendations will be made based on the initial consultation
Date: 03/19/2023, Your IP: 22.214.171.124 I agree *
All information in this questionnaire is deemed reliable but not guaranteed. All products are subject to prior sale, change, price change or withdrawal. Neither XTC Hair Rejuvenation Systems™ or information provider(s) for these services shall be responsible for any typographical errors, misinformation, and misprints and shall be held totally harmless. Products and their descriptions & information are provided for consumers’ personal & non-commercial use. These products and represented services may not be used for any other purpose other than to identify cosmetic options with the use of XTC Hair Rejuvenation Systems™ products and or services. The product and services are not to be confused with, or represented as medical treatment(s), service(s or solution(s). All information contained within this consultation agreement is to be considered non-medical.