Roxy
SENIOR LEVEL 3
ARTISTIC DIRECTOR
Online Consultation Form
Contact Information
Name
(Required)
First
Last
Email
(Required)
Phone
(Required)
Preferred Method of Contact
(Required)
Phone
Email
Text
About You
What is your reason for seeking our services? (Check all that apply)
(Required)
Thinning Hair
Hair Loss
Alopecia
Cancer
Other:
What is your reason for seeking our services? (Other)
Have you used wigs, toppers, or extensions before?
(Required)
Yes
No
Which solution are you most interested in learning more about?
(Required)
Wigs
Hair Toppers
Hair Extensions
Not Sure Yet
Your Comfort & Preferences
Would you prefer an in-person or virtual consultation?
(Required)
In-Person (Private Room)
Virtual (Video Call)
How soon are you looking to schedule your consultation?
(Required)
As soon as possible
Within the next week
Within the next month
Just gathering information for now
Is there anything you'd like us to know before your consultation?
Optional Photo Upload
To help us better understand your needs, you may upload a current photo of your hair or scalp (this is optional and confidential).
Accepted file types: jpeg, jpg, png, gif, webp, pdf, tiff, heic, Max. file size: 50 MB.
Consent
(Required)
I understand this is a private and confidential consultation and agree to be contacted by Asante Salon for scheduling.
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