Cranial Prosthesis Intake Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Client Information & Contact Details This information is used for consultation records, service coordination, and documentation support. Name *FirstLastPreferred NameDate of Birth *Phone *Email *Occupation: *AddressAddress Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmergency Contact Name *FirstLastEmergency Contact Phone: *Preferred method of communication: *— Select Choice —Phone callText messageEmail photos Have for Hair Loss History & Scalp ConcernsThis section helps identify contributing factors related to hair thinning, shedding, scalp discomfort and overall hair wellness history.1. What is your primary hair concern? *Hair thinningExcessive sheddingBreakageBald spotsScalp irritationDrynessSlow growthPost-chemical damagetraction/tension-related concernsMedical-related hair lossHereditary hair lossOtherIf other, please list here.2. When did you first notice changes in your hair? *— Select Choice —Less than 3 months ago3-6 months ago6-12 months ago1-3 years agoMore than 3 years agoUnsureThe loss will come post medical treatments3. Have you previously been diagnosed with a scalp or hair loss condition? *YesNoUnsureIf yes, please describe diagnosis or condition.4. Have you worn any of the following within the last 12 months? *ExtensionsWigsGlue/tap adhesivesBonnets/Hair TiesChemical Alterations Temporary/PermanentNoneOtherIf other, name here.5. What are your goals for your hair?Hair Systems & Service ConsiderationsThis section helps to identify previous hair replacement experience, service interests, sensitivity concerns and consultation goals to support appropriate system recommendations and care planning.1. Have you previously worn a wig, topper or hair replacement system? *— Select Choice —YesNo2. Which option are you most interested in exploring? *Cranial prosthesisWig/UnitHair topperUnsure – need guidanceOtherIf other, list here.3. Have you experienced sensitivity to adhesives, tape or hair products? *YesNoUnsureIf yes, please explain.4. Are you interested in insurance documentation support if applicable? *YesNoUnsure5. What are your primary goals for this consultation? *Photo Uploads & ConsentClear photos assist with consultation review, hair/scalp assessment, service planning, and documentation support. Please upload recent photos in neutral lighting when possible. 1. Please upload current photos of your hair/scalp. * Drag & Drop Files, Choose Files to Upload Recommended views: Front hairline, Left side, Right side, Crown/top area, and Areas of concern.2. Please upload photos of your desired finished look. * Drag & Drop Files, Choose Files to Upload Recommended views: Front, profile and back of a photo of your desired look. This can be inspiration from another model or previous photos of yourself.3. Do you authorize Sijaché to use non-identifiable before and after images for educational or professional purposes?YesNo4. I understand that this consultation is intended for hair wellness, hair replacement, and cranial prosthesis support services and does not replace medical diagnosis or treatment. *I acknowledge and understand .Submit
