Trichology Center - Hair Loss and Scalp Treatments- Arlington Tx • DFW
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    CONFIDENTIAL Hair Loss/Restoration Consultation Questionnaire

    Please fill out as accurately as possible and completely, so I can better serve your needs.  Thank you.

    ​Briefly give us your background story of your primary hair problem and when it started including age of onset.


    Medical History

    Females Only


    Males Only


    NUTRITION

    CONDITIONS OF THE SCALP
    In each box below, please list any medications or supplements you are taking along with its' symptom/diagnosis & how long you've been taking medication.

    HEREDITARY
    RELATIVES
    What are your goals and expectations? 

    Max file size: 20MB
    You can upload a visual photo of your hair loss to further help me prepare for our consultation.
    Max file size: 20MB
    You can upload a visual photo of your hair loss to further help me prepare for our consultation.
    Max file size: 20MB
    You can upload a visual photo of your hair loss to further help me prepare for our consultation.
    Max file size: 20MB
    You can upload a visual photo of your hair loss to further help me prepare for our consultation.

    Consent for Treatment 
    I am being evaluated by The Hair Recovery Center and understand I will first undergo a comprehensive preliminary evaluation by an experienced hair loss consultant.  This preliminary evaluation will include a complete and thorough medical and hair loss questionnaire, a scalp evaluation if available which includes standard medical photography (no face shown), and microscopic photography for which I give consent.  I also understand that although The Hair Recovery Center has had many very successful clients, each client is different and like any medical or cosmetic treatment, results will vary depending on a large number of factors.  I acknowledge it is my responsibility to inform The Hair Recovery Center of any changes in my medical condition no matter how slight and agree to read all product labels and treatment information provided to me so I can understand my treatments and get the best possible results.

    I understand some general recommendations will be made based on the initial consultation.
    Please upload photos of the problem areas of your hair and scalp in the upload boxes below.
Submit
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The Hair Recovery Center of Arlington,
​   Trichology & Wellness Clinic
  
2611 S. Cooper St., Ste 121
Arlington, Texas 76015
​682-320-8443
​
www.TheHairRecoveryCenter.com

Receive Your Trichology Certification!
www.InstituteOfTrichologyStudies.com
Advance Trichology Services - Holistic Hair Loss & Hair Restoration Treatments and Services in DFW - Arlington, Texas offers the latest, most natural hair loss solutions, non-surgical hair replacement, hair restoration procedures, wigs and hair loss treatments.
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  • HOME - Hair Loss Center-Arlington Tx DFW
    • Our Restoration Center >
      • Your First Visit
  • Hair Loss Before & Afters Images
  • Shop Hair Care and Growth Products
  • About Hair Loss
    • Understanding Hair Loss
    • Mens Hair Loss-DFW
    • Womens Hair Loss-DFW
  • Low Level Laser Therapy
  • Clinical Scalp Treatments
  • Hair Loss Services and Solutions
  • Arlington Trichology Services
  • Institute of Trichology Studies
  • Contact
  • Salon Referral Program
  • Thin Edges Beauty Box