Scalp Diagnostic Consultation Form – House of Henshaw | Hair Salon in Aigburth, Liverpool

House of Henshaw | Hair Salon in Aigburth, Liverpool

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Scalp Diagnostic Consultation Form

Your journey to a calmer,healthier scalp begins here.

At Serenity, every treatmentbegins with understanding of your scalp, your lifestyle, and your wellbeing.

Please complete this short consultation form so our specialists can prepare a tailored plan for your first visit.

Your Details

Full name

Date of birth

Email

Contact Number

Have you visited Serenity before

No Yes

How did you hear about us

Instagram Google Recommendation Other

If Other please specify

Scalp Concerns

Your scalp concerns

Itchy or irritated scalp Flaky or dry scalp Oily or greasy scalp Tightness or discomfort Redness or sensitivity Hair shedding or thinning Scalp breakouts or congestion Other

Other scalp concerns

Please tell us what you are currently experiencing

When did you first notice these concerns

Factors that make it better or worse

Stress Hormonal changes Diet Product use Weather Medication Other

Other factors

Hair & Routine

How often do you wash your hair

What products are you currently using

Do you use dry shampoo or scalp oils regularly

No Yes

Changes in hair texture strength or density

Internal & Lifestyle

Are you currently taking any medication or supplements

Known allergies or skin conditions

No Yes

If yes please specify

Are you currently pregnant or breastfeeding

No Yes

Have you noticed recent hormonal changes

No Yes

Do you experience high levels of stress or anxiety

No Yes

Typical daily diet

Do you follow any specific diet

Do you smoke or vape

No Yes

Alcohol intake

Occasional Regular None

Average hours of sleep per night

Water intake approximate glasses per day

Previous Treatments

Have you seen a doctor dermatologist or trichologist before

No Yes

If yes please provide details or diagnosis

Have you used prescribed scalp products or medicated shampoos

No Yes

If yes please specify prescribed products

Your Goals

What would you most like to achieve

Relief from irritation or discomfort Reduce flaking or oiliness Restore balance and comfort Support for hair growth or shedding Improve overall scalp health and confidence Other

Other goals

Consent & Privacy

By submitting this form, I can confirm that the information provided is accurate to the best of my knowledge and consent to Serenity storing my details securely in line with GDPR regulations.

I consent to before & after photos being taken for internal progress tracking

I'm happy for my photos to be used on the Serenity Scalp Clinic

Before picture upload

Once submitted, a member of the Serenity team will review your form and contact you to arrange your Scalp Diagnostic Consultation £60

You’ll receive:
• Microscopic scalp imaging
• Trichology-led analysis
• Personalised treatment and homecare plan

Any questions please get in touch our friendly team our waiting to answer your questions.

303 Aigburth Rd, Liverpool L17 0BJ
0151 727 6300
07368 655565
info@houseofhenshaw.co.uk

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303 Aigburth Rd, Liverpool L17 0BJ
0151 727 6300
H.ofhenshaw@hotmail.com

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