Virtual Consultation Intake Form

Please complete this form at least 24 hours before your appointment so Dana has time to review your information before you meet.

First name*

Last name*

Email*

Phone number

What would you most like help with?*

Which concerns are you experiencing?

Thinning

Increased shedding

Breakage

Dryness

Oiliness

Itching

Flaking

Tenderness

Changing texture

Other

When did you first notice these changes? Have they been sudden or gradual?

Where do you notice the changes most?

Hairline

Temples

Part

Crown

Throughout

Other

Have you noticed any sores, bleeding, significant redness, or painful areas?

What products do you currently use, and how often do you wash your hair?

Do you color, lighten, chemically treat, heat style, or wear extensions or tight hairstyles?

Have you experienced any recent changes you feel may be relevant, such as menopause, illness, surgery, significant stress, diet changes, or starting or stopping medication?

Are there any allergies or sensitivities I should know about, including fragrance, botanicals, or essential oils?

Have you seen a healthcare provider or dermatologist about these concerns? Are you following any recommendations?

What would you most like to leave our consultation with?

Anything else you'd like me to know?

I understand this virtual consultation provides cosmetic hair and scalp education and personalized care guidance. It does not provide a medical diagnosis or replace care from a licensed healthcare professional.

I'd like to receive hair and scalp tips, seasonal offers, and updates from Soul Gypsy Salon & Sanctuary.

“A Sanctuary for Hair, Scalp & Soul”

Experience personalized hair artistry, organic botanical products, and restorative scalp rituals in a welcoming space where beauty and well-being come together.
Rooted in Healing. Guided by Nature.

805.674.3082

831.808.9183

www.soulgypsysalonsanctuary.com

7770 Eigleberry St

Suite B

Gilroy, CA 95020

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