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Hair Program Enquiry Form
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Thank you for your response. ✨
Full Name
(required)
Email
(required)
Phone
How did you hear about us?
Select one option
Search engine
Social media
TV
Radio
Friend or family
What are your main hair concerns right now?
Hair thinning
Excess shedding
Dry or brittle hair
Scalp issues (itchy, oily, flaky)
Increased greys
Damage from colouring
Hair not growing
Other
If other was selected, please provide more information.
When did you first notice these changes?
Have you experienced any of the following recently?
High stress
Hormonal changes (postpartum, perimenopause etc)
Weight loss or diet changes
Illness or medication changes
None of the above
Are you currently colouring your hair?
Yes (regularly)
Occasionally
No
How often do you wash your hair?
How would you rate your current stress levels?
Low
Moderate
High
How is your energy day to day?
Consistent
Up and down
Constantly fatigued
Do you feel your nutrition is supporting your health?
Yes
Somewhat
Not really
What would your ideal hair look and feel like?
What is your biggest frustration with your hair right now?
Are you open to a holistic approach that includes scalp treatments, nutrition and lifestyle support?
Yes, absolutely
I'm open but want to learn more
Not sure yet
Results take consistency. Are you willing to commit to a structured plan to improve your hair?
Yes
Maybe
Not right now
My Hair Recovery Programs range from $300-$1,500 depending on your needs. Are you comfortable investing in your hair and wellness if it’s the right fit?
Yes
I'd like more information
Not at this stage
Are you ready to book your consultation?
Yes; as soon as possible
Within the next few weeks
Just enquiring for now
Is there anything else you would like me to know about your hair or health?
Send
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