the HEIR HAIR SYSTEMS ONLINE CONSULTATION FORM

Name *

First Name

Last Name

Phone *

(###)

###

####

Checkbox *

Would you prefer a private consultation room?

Yes please

No, I’m comfortable either way

Not sure yet

Where are you experiencing thinning or loss? *

Hairline

Crown / Top

Sides

Overall thinning

Patchy hair loss

Complete or near-complete hair loss

What have you tried so far? *

Extensions

Toppers or wigs

Volumising products

Nothing yet

Other

Are you currently taking any medication or undergoing any medical treatment that could affect hair? *

Yes

No

I'd prefer not to say

Tell us about your lifestyle *

Very active, swim and exercise reguarly

Wear protective headgear e.g horse riding

Regularly travel and have holidays

Big event coming up, eg wedding.

Consent & Privacy *

Your information is handled with the highest level of sensitivity, privacy and care. We will never share your data without consent.

I consent to HEIR Salon securely storing and reviewing the information I’ve provided in order to assess the best hair system solution for me. I understand this form does not provide a medical diagnosis.1

I agree to be contacted by HEIR Salon by email or phone for the purposes of my consultation.

I understand my data will be handled in accordance with the HEIR Privacy Policy