Hair Report | Hairology - 'The Root to Healthier Hair'.




This form is designed for us to be able to recommend the best course of treatment to suit your individual condition and needs. You will be given various options of treatments available depending on whether your condition is 'severe', 'moderate' or 'mild'. Please try not to leave any questions unanswered. Any questions left unanswered will be treated as not applicable to you. Your Hair Report will be emailed to you at the email address you have provided within 48 hours. All questions marked with a blue asterisk* must be completed in full.

Your Details Please complete all sections.* Your Full Name (title, first, surname)* Contact No* Email* Age* Male* Female* Occupation* How did you hear about Hairology?* Do you have any health issues? (please specify)* Any weight changes? (please specify)* Is your concern a?* Hair Loss Problem Scalp Problem Is your condition?* Severe Moderate Mild Any previous treatments or advice? (please specify)*	HAIR LOSS Please complete all sections applicable. Do you lose hair when washing? Do you lose hair when brushing your hair? Do you feel your hair is generally thinning? Do you feel your hair is thinning but don't notice any hair loss? Do you have patches of hair loss? Is your hair dry, dull and lifeless? Please explain what you have been experiencing? SCALP PROBLEM Please complete all sections applicable. Is your scalp? Normal Oily Dry Is your scalp flaky? Is your scalp itchy and irritable? Is your scalp inflammed and sore? Does your scalp weep or bleed? Is there a crusty build up on your scalp? Please explain what you have been experiencing?

HAIR CARE Please complete all sections applicable. How often do you wash your hair? What type of shampoo do you use? Do you use a conditioner? How do you dry your hair? Is your hair natural, coloured or permed? What styling products do you use? Please Click here to Reset Form	Any Further Comments (please add) At Hairology we are committed to protecting your privacy. The information we collect about you is to provide with a more personalised service and Hair Report, which is based only on the information you have provided. Hairology cannot be held responsible for any false or inaccurate information provided by you. By ticking this box and the submit button, you authorise and consent to the collection and use of this information by Hairology. All information is treated in the strictest confidence and for the use of Hairology only, your details are not shared with any third party. We respect your privacy. By clicking submit, you hereby state that you have read, undertsood and accept these Terms and Conditions and all answers to the above questions are true to the best of your knowledge. Please Click here to Proceed