Skip to content
CONSULTATION FORM
CONSULTATION FORM
Cockatoo Hairy Styling Gel Consultation Form
Step
1
of
3
33%
Name
(Required)
First
Last
Date of Birth
(Required)
DD slash MM slash YYYY
Gender
(Required)
Male
Female
Address
(Required)
Street Address
City
ZIP / Postal Code
Email
(Required)
Phone
(Required)
Do you have any allergies?
(Required)
Yes
No
If yes, please list your allergies
How does your Hair loss look?
(Required)
Choice number 1 does not have an image
First Choice
Choice number 2 does not have an image
Second Choice
Choice number 3 does not have an image
Third Choice
Have you experienced a sudden loss of your hair over a few days or weeks?
(Required)
Yes
No
Are you experiencing any symptoms around Scalp? E.g. Itchiness, redness
(Required)
Yes
No
If Yes, please list your symptoms
Do you currently have any medical conditions?
(Required)
Yes
No
If Yes, please provide details
Are you taking any regular medicines?
(Required)
Yes
No
If yes, please provide medication details.
Final Declarations
(Required)
I Confirm
I confirm that the information provided is accurate and complete to the best of my knowledge. I understand that this treatment is prescribed based on the information I have provided. I consent to my information being reviewed by a registered prescriber.
Confirm
I Understand
Your order is NOT confirmed yet.
All orders require prescriber approval before dispatch.
If your application is NOT approved, we will issue a FULL refund.
If approved, your product will be dispatched, and you will receive an email confirmation.
If you have any questions, contact our support team at 0208 191 3034.
Δ
