Schedule a Consultation Today!

902-429-8300

Virtual Consultation

At Ultra Hair Solutions & Esthetics, we understand that your time and privacy are very important. That’s why we offer a virtual consultation – so you can get the answers you need about your hair loss and rejuvenation options from the comfort of your home.

Please fill out this questionnaire so that we can learn about your particular hair loss and determine a preliminary diagnosis and potential treatment options.

Keep in mind: This questionnaire and our reply cannot take the place of an in-person consultation.

Questionnaire

Please fill out the form below to the best of your ability!

Name*

Email*

Address

City*

Province*

Postal Code*

Phone*

Date of Birth

Biological Sex
MaleFemale

Occupation

Do you lead an active lifestyle?
YesNo

What are your expectations from Ultra Hair & Esthetics?

When did your hair start thinning?

How would you describe your current hair loss?

Does baldness/thinning hair run in your family?
YesNo

Have you seen a physician regarding your hair loss?
YesNo

What product(s) do you use on your hair?
ShampooConditionerHair ColouringOther (See Below)

Other Products

How often do you use each of these products?

Are you on a hair treatment program?
YesNo

If yes, which one and what are the results?

Do you suffer from:

If other, please specify:

Would you characterize your existing har as:
DryOilyNormal

The hair you are losing is:

Does your scalp excrete excessive sevum (oil)?
YesNo

Are you presently experiencing (Check all that apply)
Professional StressMedical TreatmentPersonal StressSicknessSevere DietMenopauseMedicationPregnancy

If you checked any, please describe

On a scale from 1 to 10, how would you rate the emergency to treat your hair loss? (1 being the lowest, 10 the highest)
12345678910

Who supports your decision to treat your hair loss?

How would you like your new "look" to be?

Do you presently have or have you ever had any type of surgical or non-surgical hair replacement?
YesNo

Comments?

I understand that the information I provide will be kept in complete confidentiality and will not be distributed, sold or used for any other purposes than for us to communicate with you.
Yes