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Hair Scalp Laser Clinic
1355 Automotive Blvd
Suite 110
Clearwater, Florida 33762
Questions? Call 800-883-4247
and Ask For John Satino
Three Steps For Your FREE Hair Analysis
1. Print this form
2. Complete the requested hair sample and information
3. Mail your hair sample and information on this form to
Hair and Scalp Laser Clinic, 1355 Automotive Blvd.,
Suite 110, Clearwater Florida 33762
Microscopic Hair Analysis
First Name __________________________Last Name_________________________________
Address
________________________________________________________________
City: ________________________________State: ____________ Zip:
_____________
Phone: _______________________ Email
Address______________________________
Brief History:
1.
List any medications you are
taking:________________________________________
_______________________________________________________________________
2. List the vitamins you take if
any:___________________________________________
3. Presently losing your hair? Yes____ No____
4. Do you have dandruff? _____Any other scalp condition? Describe:
________________
_______________________________________________________________________
5. Have you ever used any hair loss treatment? Ex. Medications for
hair loss, Rogaine,
Propecia, Low Level Laser:
Describe:__________________________________________
_______________________________________________________________________
6. Please list any medical conditions. For example, high
cholesterol, high blood pressure, diabetes, other:
__________________________________________________________
________________________________________________________________________
7. Additional Comments:
____________________________________________________
________________________________________________________________________
________________________________________________________________________
Hair Sample Directions:
-
Use Tweezers To Remove Hair Requested For This Analysis
- Use Clear Tape To Attach The Hair Samples
1. Remove several strands of hair including the root from the
frontal area.
__________________Tape Here_________________________________
2. Remove several strands of hair including the root from the top
back or crown area.
__________________Tape Here_________________________________
3. Remove several strands of hair including the root from the nape
of the neck behind the ear area.
__________________Tape Here_________________________________
Please Allow Two Weeks For Test Results
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