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Virtual Consultations

Get a Virtual Consultation from Ultra Hair Solutions & Esthetics


At Ultra Hair Solutions & Esthetics, we understand that your time and privacy are very important. That’s why we offer a virtual consultation – so you can get the answers you need about your hair loss and rejuvenation options from the comfort of your home.


Please fill out this questionnaire so that we can learn about your particular hair loss and determine a preliminary diagnosis and potential treatment options.


Keep in mind: This questionnaire and our reply cannot take the place of an in-person consultation.


If you have any questions, please contact us.

Identification & Questionnaire

Male
Female
Yes
No
Yes
No
Yes
No
Shampoo
Conditioner
Hair colouring
Yes
No
Yes
No
Professional stress
Medical treatment
Personal stress
Sickness
Severe diet
Menopause
Medication
Pregnancy
1
2
3
4
5
6
7
8
9
10
Yes
No
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