Hairology, Hair Loss Treatment, Specialists, Dry Scalp Treatment Specialists, call 0800 270 7683 or email: hair@hairology.co.uk
Hair Report heading
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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.

Please note the report is based solely on the information you have provided, and on our experience and knowledge,
we cannot be held responsible for any inaccuracies provided by you.

Our commitment to you is simple; we are here to improve your quality of life by providing you with the healthiest head of hair
and problem free scalp as possible. We pride ourselves in our service, online, by phone, by email, at your convenience,
there is no restriction on how many times or how long you need to speak to us, we’re here to help.

Our quality, tried & tested solutions, will ensure you receive the very best advice, treatment & products
specifically tailored to your needs.

All questions marked with a blue asterisk* must be completed in full.

Thank you for choosing us.

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Your Details
Please complete all sections.*

Your Full Name (title, first, surname)*

Contact No*


Email*

Age*

Occupation*

How did you hear about Hairology?*

Do you have any health issues? (please specify)*

Any weight changes? (please specify)*

Any previous treatments or advice? (please specify)*

Did it help? (please specify)*

HAIR LOSS
Please complete all sections applicable.







Please explain what you have been experiencing?

SCALP PROBLEM
Please complete all sections applicable.

Is your scalp?




Is there a crusty build up on your scalp?



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HAIR CARE
Please complete all sections applicable.







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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 tailored Hair Report, which is based solely 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.

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Hairology - Hair Loss Products - Dry Scalp Treatments - Alopecia Treatments - Copyright All Rights Reserved. 0800 270 7683 or email: hair@hairology.co.uk