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STEP 1 _________________________________________________________________________________________________________
NEW CLIENT INFORMATION FORMS
Namefull name
Dateof appointment
Chart #
DOB
Age
Home PhoneHome Phone
Cell
Address
City
State
ZIP
In case of Emergency Contact
Namefull name
Phone
Employed byEmployed by
Work PhoneWork Phone
Address
City
StateState
ZIP
Responsible Party (if other than client). Responsible party accepts financial responsibility by signing below
Namefull name
Home PhoneHome Phone
CellCell
Work PhoneWork Phone
DOBDOB
Relationship to Client
Employed by (if different from above)Employed by (if different from above)
Address
City
State
ZIP
Do you have health insurance? If so, what kind?
* If client is under 18 years old, please present Driver's License of responsible party for photocopy
Agree
Type your initials heresomething more
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STEP 2 _________________________________________________________________________________________________________
CONSULTATION | CLIENT PROFILE FORM
Namefull name
CellCell
Home PhoneHome Phone
DOB
Address
City
StateState
ZIP
Occupation
Did anyone refer you? If so, please list referral
When was your last visit?
What services did you receive?
Chemical services that you have received in a salon:
If so, what type?
If so, last relaxer?
If so, what type?
If so, when?
If so, what type?
If so, when?
If so, when?
What kind of service and brand name?
Salon and Stylist/Barber name
What beauty services do you usually require?
If in a salon, please give the name and address of salon
To the best of your ability, explain what you think may have happened
If so, what treatments were recommended?
If so, what type?
Which styling implements do you use at home?
Please list any chemicals that you use at home
Agree
Type your initials heresomething more
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STEP 3 _________________________________________________________________________________________________________
INFORMATION | HAIR LOSS ISSUES
Please give us information about your hair loss issues and health problems.
Hair Loss Issues
When did the problem start?
Health problems
When did the problem start?
-- Vitamins --
Please list all vitamins you are currently taking
For what purpose are you taking the vitamins?
Who recommended the vitamins?
-- Herbs --
Please list all herbs you are currently taking
For what purpose are you taking the herbs?
Who recommended the herbs?
-- Medications --
Doctor's Name
Please list all medications you are currently taking
If so, please list allergies
-- Hair Care Products --
Please list the brand name of products you are currently using in your home.
Shampoo
Conditioner
Hair Spray
Scalp Oil
If so, please list
CLIENT IN­-TAKE FORM
Do you take any of the following?
If so, what?
Injectable numbing medications:
Other
If so, what?
Do you have any reactions to:
If so, what?
How much do you weigh?
Cardiovascular
Other
Ears, Nose, Mouth
Eyes
Genitourinary
Hormones
If so, when?
Please explain results:
If pregnant, how many months?
Other
Lungs/Respiratory/Endocrine
Internal
If so, when?
Musculoskeletal
Gastrointestinal
Explain
How much water intake?
Skin
What type?
Neurology Medical History
Explain
Other serious illness or problem
Hair Loss
If yes, when did the problem start?
Explain hair loss problem
Hospitalization (Last 10 Year)
Reason
When
Cancer History
What type of cancer?
Malignant Melanoma
What type of cancer?
Malignant Melanoma
Family History
Do any immediate (blood) family members have any of the following? (Grandparents, mother, father, brothers, sisters, aunts, uncles) (Do not consider yourself)
who
who
who
who
who
who
who
who
Social History
What level of education did you complete?
What is your current occupation and work environment?
If yes, how many?
Age(s)
If yes, what kind?
If yes, what type?
At what age did you begin?
Hobbies
STEP 4 _________________________________________________________________________________________________________
HAIR LOSS CENTER OF ATLANTA RELEASE WAIVER FORM
I
Type your name here
authorize and release the Hair Loss Center of Atlanta (HLCA) from any pre­existing hair loss problems as it relates to my hair loss and scalp disorders consultation . I further release the Hair Loss Center of Atlanta from any lawsuits or claims that come as it relates to any services that I may receive. HLCA has my permission to receive any information necessary from my previous stylist and medical professionals for purpose of clinical research.
I authorize information directly to HLCA of care listed above. I agree that photographs, photographic and electronic copies of this authorization shall be valid. I give permission for documentation and photographs of any pre­existing problems to be taken and used by HLCA.
Agree
Participant (Guardian if Minor)Participant (Guardian if Minor)
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Dateof appointment
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