Licensed Hair Care Professionals and Dermatologists Referral Form

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This form is for licensed hair care professionals and dermatologists who want to be included on our referral list.

The information you provide will be used to match clients with the right professional for their needs.

We are always looking for qualified professionals to refer our clients to.

Name *

Licensed? *

Yes

Business Name *

Business Address *

Business Email *

Business Phone *

Website Address / Scheduling Link *

What services do you specialize in? (Really enjoy doing) *

Cuts

Relaxers

Natural Hair

Color

Barbering

Locs

Braids

Steam treatments

Hair Loss Treatments

Kids Styles

N/A

Other:

Required

List any additional speciality

What type of hair loss treatment do you provide? *

Minoxidil (Rogaine): A topical medication that can help to stimulate hair growth.

Finasteride (Propecia): A prescription medication that can help to block the effects of testosterone on hair follicles.

Low-level laser therapy: A treatment that uses lasers to stimulate hair growth.

Platelet-rich plasma (PRP) therapy: A treatment that uses platelets from the patient's own blood to stimulate hair growth.

Scalp micropigmentation: A cosmetic procedure that can create the appearance of fuller hair.

N/A

Required

What type of hair replacement do you provide? *

Follicular unit transplantation (FUT): A surgical procedure that involves transplanting hair follicles from one part of the scalp to another.

Follicular unit extraction (FUE): A surgical procedure that involves extracting individual hair follicles from one part of the scalp and transplanting them to another.

Hair weave: A temporary hairpiece.

Hair extensions: Permanent or semi-permanent hairpieces.

Cranial prosthesis: a custom-made wig or hair unit

N/A

Required

Experience

What do you desire from this collaboration? *

Thank you!

Visit www.hairwellnessgroup.com to learn more about our products and coaching.

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