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Intake Form
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Intake Form
Name
Address
Phone
Email
Date of Birth
How did you hear about Revive Hair Restorations?
Internet
Friend
Instagram
Stylist
Other
Do you have any allergies?
Hayfever
Asthma
Shellfish
Other
Current Medications
Are you currently taking any medications?
Minoxidil
Propecia
DHT Blockers
Hair Growth Supplement
Blood Thinners
Do you currently have any hair enhancements ?
Hair Extensions
Hair Transplant
Bleach Color
Hair Breakage
Do you have scalp issues?
Redness
Itchy
Sores
Dry
Scabs
Oily
Dandruff
Bald Patches
Do you pull your hair?
Yes
No
Does hair loss run in your family?
Yes
No
Has your hair loss been?
Sudden
Overtime
Have you ever been Diagnosed with?
Alopecia Areata
Androgenetic Alopecia
Scarring Alopecia
Telogen Effluvium
Trichotillomania
Frontal Fibrosing Alopecia (FFA)
Lichen Planopilaris
Seborrheic Dermatitis
Folliculitis
Psoriasis
Eczema
Signature Date
Upload Scalp Image (Before Appointment)
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Fill this Patient Intake Form
