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Name
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First
Last
Phone
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Address
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Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Hawaii
Idaho
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Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email
*
Are you experiencing any of the following symptoms ? (Select all that apply)
Hair Loss
Scalp Irritation
Anxiety
Psoriasis
Insomnia
Stress
Are you Currently using anything for hair loss? check all that apply
*
Minoxidil
Nutrafol
Finasteride
Other
None
What kind of skin do you have?
Normal
Oily
Dry
Combination
Have you seen a dermatologist or other doctor for your hair loss?
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Yes
No
Have you been diagnosed with any medical condition?
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Alopecia
Cancer
PCOS
Ringworm
Over or Under active Thyroid
Anaemia
Significant Weight loss
scalp condition
Lupus
None
Other
Other (please specify):
Have you lost significant amounts of weight in a short period of time?
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YES
NO
Have you had Bariatric Surgery of any sort?
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Yes
NO
Ave you or are u currently taking any of these Medications?
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Ozempic
Metformin
Mongoro
None
Other
Other (please specify):
What kind of hair loss are you experiencing?
*
Female Patter Baldness
Male Pattern Baldness
Alopecia Areata (patchy Hair loss )
Traction Alopecia (from hairstyle pulling or hats etc.)
Frontal Fibrosing Alopecia (Gradual thinning on the top of the head or receding hairline)
Trichotilomania
Other
Other (please specify):
Have you ever had an allergic reaction to any of the following?
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Medicine
Latex
AHAs
Lidocaine
Benzocaine
Tetracaine
None
Other
Other (please specify):
Within the past 3 months, have you used Retin-A, Renova, AHAs or Retinol/Vitamin A-derivative products? If yes, please describe:
Are you over the age of 18?
*
YES
NO
ID/ Drivers Licence
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Click or drag a file to this area to upload.
Guarantee and Limitation of Liability
I am undergoing treatment of my own free will. I agree that this procedure is being performed for cosmetic reasons, and that no guarantee can be made as to the exact results of this procedure. I understand that while every precaution will be taken to prevent complications and that complications from this procedure are rare, they can and sometimes do occur. I understand that no guarantees can be or have been made concerning the expected results in my case. Multiple treatments are necessary to achieve optimal results. I understand that this procedure is purely elective. By adding my signature below, I certify that I have read and fully understand the contents of this consent form, have been given the opportunity to ask questions and that the disclosures referred to herein were made to me. I furthermore indemnify the authorized person, Chana Horowitz and/or Chana’s Beauty Llc. herein, and hold Chana’s Beauty / Chana Horowitz harmless from any and all claims, demands, liabilities, judgments, costs and expenses arising out of any claims relating to the procedure authorized herein.
Client Digital Signature
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