Name

First Name

Last Name

Phone

(###)

###

####

Which age group do you fall into? *

Under 30

30–40

40–50

50–60

Over 60

What have you already tried to help with this?

Hair extensions

Scalp treatments

Toppers/wigs

Medications

Hair thickening shampoos or supplements

Nothing yet

Other

Have you ever been medically diagnosed with a form of hair loss? *

Yes

No

Do you currently colour your hair?

Yes

NO

Occasionally

I’ve stopped because of thinning/sensitivity

What would you love to feel about your hair again? *

Confident

Feminine

Proud

Free

More like me

Low-maintenance

Strong and secure

I want to stop thinking about my hair altogether

What’s most important to you in a hair solution? *

☐ Looks natural ☐ Feels light ☐ Won’t damage my own hair ☐ Long-lasting results ☐ Affordable over time ☐ Low-maintenance ☐ Support from someone who understands

Looks natural

Feels light

Won’t damage my own hair

Long-lasting results

Affordable over time

Low-maintenance

Support from someone who understands

How comfortable are you with ongoing maintenance? *

I’m happy to visit the salon every 4–8 weeks

I’d prefer less frequent visits

I’m not sure — tell me what’s involved

Option 4

How often do you wash your hair? *

Daily

Every 2–3 days

Weekly

How active is your daily lifestyle? *

Very active (gym, running, swimming, etc.)

Somewhat active

Not very active

How ready are you to explore a solution? *

100% ready

I’m close, just want to understand more

I’m still thinking

Would you like to be contacted for a personal chat once we open bookings? *

Yes, I’d love that

No, just keep me in the loop

Maybe later