Fields marked with an * are required Full Name * Phone * Email * Ethnicity Gender Afro Hair Type see below for image on hair type Any Allergies if so, please list Where on your scalp are you experiencing hair loss? Where on your scalp are you experiencing hair loss? (Please attach pictures to this document,you may hide your face if preferred) How long have you been experiencing hair problems? How long have you been experiencing hair problems? Have you been diagnosed with a hair condition by your doctor? (If yes, please give details) Can you please state products you have been using in the past 18 months including the one you are using now? Can you please state products you have been using in the past 18 months including the one you are using now? How often do you wash your hair? How often do you wash your hair? Do you do hair treatments? If yes, how often? Do you do hair treatments? If yes, how often? Do you wear wigs? If yes, please state how often? Do you wear wigs? If yes, please state how often? Which applies to your hair, low porosity or high porosity? Which applies to your hair, low porosity or high porosity? Is your hair relaxed or is it in its natural state? Is your hair relaxed or is it in its natural state? How often do you moisturise your hair? How often do you moisturise your hair? Do you protect your hair when going to Bed? Do you protect your hair when going to Bed? If yes, please tell us with what you protect your hair with and what material? How many litres of water do you drink per day? How many litres of water do you drink per day? Do you consume alcohol if so, please state how often you do so? Do you consume alcohol if so, please state how often you do so? Please State any relevant information you need to tell us. Please State any relevant information you need to tell us. Which hair type applies to your hair? If you are a human seeing this field, please leave it empty.
