Intake Form | NHC Formula

Have You Consulted With Other Hair Replacement Professionals?

Have you wore a hair replacement before? (wigs, sewin, hair topper, crochets)

Are you wearing a hair replacement today?

Is hair loss heriditary in your family?

Have You Been Treated For Hair And/ Or Scalp Problem?

Are You Presently Taking Any Medications?

Do you need someone (Other Than Yourself) to assist in the decision to correct your hair loss problem?

Are you able financially, at this time to do something about your hair loss?

Are you generally in good health?

Are you presently under a doctor care?

Have you had a prior hair transplant?

Have you ever had any types of bleeding disorders?

Do cuts on your skin heal normally?

Do you have any tendency toward keloids? (raised riged scars)

Have you required additional anesthesia at the dentist?

Have you ever had allergic reactions to anesthesia?

Have you ever had any allergic response or adverse reactions to substances put onto your skin?

Do you take large amounts of aspirin ?(More Than Recommended)

Have you had any allergic responses or adverse reactions to any drugs or medications?

Do You Have Medical Insurance

If Yes, Does Your Insurance Plan Cover Hair Loss, Alopecia, Cranial Prothesis, Baldness or Any Other Hair Loss Related Issues?

Have You Been Treated By A Doctor For Hair Loss?

Novi Te Hair Loss Replacement Service