Hair Beauty Intake Form
From Dr. Lor: Hair Beauty clients must be pre-screened and photos of your hair concerns will be sent to me during your step 2 prescreening process.

I do a majority of my communication through email, texting, and video calls. It is expected that you check your emails and text messages to stay in communication with me. If you do not check your emails & text messages nor do you respond back, then my practice may not be a good fit for you. Please consider this before moving forward. 
Below are contraindications to Microneedling. Please check off the ones that apply to you currently *
Today's Date *
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How did you find out about us? *
Full Name *
Your parents full name, if under 18
Your legal guardian(s), if under 18
Date of Birth *
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Email address *
Best Contact # *
Can we leave voice messages or text messages on your contact #? If you listed more than 1 contact # above, please list which # we can leave messages on *
Required
Complete physical address  *
Complete mailing address, if different
Emergency contact person, relationship, and # *
Who do you allow access to your chart so that they may request information or discuss about your health, on your behalf? Please list their full name(s), relationship, and contact #. *
What are your known allergies (food, medications, or other)? *
Marital Status *
Occupation and if your job/career is stressful. *
Do you have any metal implants or devices implanted in your body? If so, where and since when? *
Who is currently part of your medical team? Please include your practitioner's name &  clinic name *
What concerns do you have about your hair? *
When did your hair loss approximately start? *
Where are you experiencing hair loss? *
Is your hair loss *
Required
Was onset of hair loss *
Required
Since onset, has it gotten *
Required
Is your hair *
Required
Does your scalp itch? *
Required
Is your scalp flaking? *
Required
How often do you wash your hair? *
What are all of your hair products? Incude brand. *
Do you use *
Required
How often do you use the above? *
Which hair styles do you regularly have? *
Required
How often do you use the above? *
What kind of treatments have you tried for hair loss and did they work? *
Do you see a rash in your scalp or on your face? *
Are you or have you been under a Dermatologist's care for hair loss? What is your care plan, if any? *
Please list all other prescription medications and supplements you are taking *
Past medical history: Check  P or C for conditions that you have had in the past or are currently experiencing. Leave those that do not apply blank. *
Past
Current
N/A
Wear contact lenses
Herpes Virus (cold sore)
Skin Cancer
Other cancer
Thyroid disease
Diabetes
Allergies
Neuromuscular condition
Hormone Therapy
High blood pressure
Low blood pressure
Heart disease
Latex allergy
Epilepsy/seizures?
HIV
Covid 19
Hepatitis
MRSA
Spider veins
Hospitalizations/Surgeries (procedures and dates) *
What significant trauma (car accidents, sport inujries, falls, etc..) have you had and when? *
Current health and lifestyle: Do you smoke, vape or chew tobacco? *
If yes, how many/much per day? For how long now?
Do you drink alcohol *
If yes, how much per day? For how long now?
Do you have any other medical conditions and/or infectious, contagious or communicable diseases that I should be aware of before you receive your treatments? *
Sleep: How would you describe your quality of sleep? Include timing of when you go to bed, # of times your sleep is interrupted, how long it takes you to fall asleep, how long do you stay asleep for and what time do you wake up? Do you feel rested upon wakening? *
Nutrition: Please be as detailed as possible. A major area that I always address is nutrition. Please describe your average daily diet for breakfast, lunch, dinner, snacks and food you tend to crave. Include the time when you typically eat each of those meals/snack. Also include your liquids/hydration especially how much daily. *
General: Please check any of the following symptoms that you are currently experiencing *
Required
Emotions: Please check any of the following symptoms that you are currently experiencing *
Required
Skin: Please check any of the following symptoms that you are currently experiencing *
Required
Neuro-muscular: Please check any of the following symptoms that you are currently experiencing *
Required
Cardiovascuar: Please check any of the following symptoms that you are currently experiencing *
Required
Respiratory: Please check any of the following symptoms that you are currently experiencing *
Required
Gastrointestinal: Please check any of the following symptoms that you are currently experiencing *
Required
Lymphatic: Please check any of the following symptoms that you are currently experiencing *
Required
Liver/Gall bladder function: Please check any of the following symptoms that you are currently experiencing *
Required
Eyes: Please check any of the following symptoms that you are currently experiencing
Urinary: Please check any of the following symptoms that you are currently experiencing *
Required
Female: Please check any of the following symptoms that you are currently experiencing *
Required
Do you experience any of the following associated with period each month? *
Required
First day of your last menstrual period (if not in menopause)
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Are your menstrual cycles spaced regularly? *
Cycle length (from Day 1 up to the last day before you menstruate again)
How many days do you bleed for and tell me about the amount of blood flow you get?
Hormonal birth control use
Are you in menopause? If yes, when?
If you are experiencing menopausal symptoms, please describe.
Females: Is there any possibility you are pregnant now? 

***You must let Dr. Lor know when you are pregnant. Services and products used may need to be discontinued until after pregnancy.
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Are you consistent with taking supplements? *
Do you have difficulties swallowing capsules, softgels or pills? *
Do you prefer capsules or teas? *
Do you have any other info that Dr. Lor needs to know about? *
By typing in your full name below, you are acknowledging that the information provided above are true and accurate. *
By typing your full name you understand that you can find my consent forms for treatment/ consultations, financial agreements, notice of privacy act and HIPAA compliance as well as office policies at www.catawbanaturalhealing.com. They are listed under New Clients. You acknowledge that you have read those forms and agree to the terms listed under them. If you have any questions, you may call me at 828-999-4800 or email me at healthservices@catawbanaturalhealing.com. *
By typing in your full name below, you acknowledge that a current credit/debit card must be kept on file in order to book appointments. This current card will be used to charge your balance unless you choose otherwise and have mentioned it to me.   

You also acknowledge that there is a no show or less than 24 hour cancellation fee for all appointments.

There is a $200 fee for missing your first appointment. 

There is a $75 fee for missing your follow up appointment. 

After a total 3 no shows, less than 24 hour cancellations or a combination of the two, you will discharge as a client from our practice.
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Please type your full name if you understand the below:

I understand that Dr. Lor is a Naturopathic Doctor and a licensed Acupuncturist. She is not a primary care doctor, gynecologist, dermatologist, or an esthetician. She can not make Western diagnosis nor prescribe prescriptions in the state of NC. 

Waiver: I understand and acknowledge there are risks involved when undergoing any treatments. I have had the opportunity to ask questions regarding these risks and other possible complications. I understand that I can ask questions at any time during my care under Catawba Natural Healing. 

I understand any false or misleading information I have provided may lead to undesired results and complications and hereby waive Dr. Lor of Catawba Natural Healing, of any liability if such results or complications occur. I further understand my failure to follow post care instructions may also lead to undesired results, complications or effects and hereby waive Dr. Lor of Catawba Natural Healing, of any liability if such results or complications occur. 

I agree and assume the risk and responsibility for any and all injuries, losses or damages which might occur to me while undergoing procedure or side effects I may experience after the procedure is performed. 
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