Primary Reason for Today's Visit *
Select your primary concern
Hair Thinning or Shedding
Hair Loss or Alopecia
Scalp Irritation or Flaking
Scalp Sensitivity or Pain
Hair Breakage
Texture or Porosity Changes
Chemical Service Assessment
Extension Readiness Assessment
Custom Wig or Hair Unit Consultation
Medical Grade Cranial Prosthetic Consultation
General Hair and Scalp Wellness
How Did You Hear About Studio Nicki Spice?
Select
Instagram
Word of Mouth or Referral
Google Search
Yelp or Google Maps
Facebook
TikTok
Event or Pop-Up
Other
Current Medications and Supplements
If Yes, Describe the Condition or Pattern (Optional)
Known Allergies (Food, Environmental, or Topical)
Hair Characteristics
Natural Hair Texture
Select
1A — Straight and Fine
1B — Straight and Medium
1C — Straight and Coarse
2A — Wavy and Fine
2B — Wavy and Medium
2C — Wavy and Thick
3A — Loose Curls
3B — Defined Curls
3C — Tight Curls
4A — Soft Coils
4B — Z-Pattern Coils
4C — Tight Coils or Zig-Zag
I am not sure
Hair Density
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Thin or Low density
Medium density
Thick or High density
Chemical Service History
Most Recent Chemical Service (Type and Approximate Date)
Extension and Protective Style History
How Often Do You Wear Extensions or Protective Styles?
Select
Rarely or Occasionally
Every few months
Most of the year
Year-round
Hair Concerns and Timeline
Describe How Your Hair Has Changed Over the Last 1 to 3 Years
Rate Your Current Hair Concern Severity
Mild
Moderate
Significant
Severe
How Would You Describe Your Scalp's Overall Sensitivity?
Not sensitive
Mildly sensitive
Moderately sensitive
Very sensitive
If Yes, Please Describe the Diagnosis and Any Prescribed Treatments
Have You Previously Used Any Prescription Scalp Treatments?
Wash Routine
How Often Do You Wash Your Hair?
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Daily
Every 2 to 3 days
Once a week
Every 2 weeks
Monthly or less
Heat and Styling Tools
Frequency of Heat Tool Usage
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Daily
Several times a week
Once a week
Occasionally
Rarely or Never
Typical Heat Setting Used
Select
Low (below 300°F)
Medium (300 to 380°F)
High (380°F and above)
Maximum
Sleep and Protective Practices
Diet and Lifestyle
How Would You Describe Your Overall Diet?
Select
Balanced or Varied
Vegetarian
Vegan
High protein
Low calorie or Restricted
Inconsistent
Current Stress Level
Low
Moderate
High
Very High
In Your Own Words, What Would a Successful Outcome Look Like for You?
Is There Anything Else You Would Like Your Practitioner to Know Before Your Consultation?
Your intake is confidential and reviewed only by your assigned practitioner before your consultation. Submitting this form is not a booking. Your practitioner will follow up within 48 hours to schedule your appointment. The information provided does not constitute a medical diagnosis and is used solely to inform your trichology protocol.
Nutritional Intake
If Yes, List All Supplements You Take for Hair, Skin, or General Wellness
If Yes, What Deficiencies Were Identified and Are You Currently Treating Them?
Do You Follow Any Specific Dietary Restrictions or Elimination Diets?
Hormonal and Reproductive Health
If Yes, What Type and How Long Have You Been Using It?
Physical Activity and Overall Wellness
Is There Anything About Your Lifestyle or Nutrition That You Believe May Be Affecting Your Hair or Scalp?
Hormonal Health — Age and Sex Specific
Describe Any Abnormal Hormonal Lab Results and How They Are Currently Being Managed
Additional Notes on Your Hormonal Health That You Feel Are Relevant
HIPAA Privacy Notice
Studio Nicki Spice is committed to protecting the privacy of your personal health information. The information collected in this intake form is used solely to inform your trichology consultation and the services provided to you by our licensed practitioners.
Your health information will not be sold, shared with third parties, or used for marketing purposes without your explicit written consent. Information may be shared with collaborating healthcare professionals only when clinically necessary and with your knowledge.
You have the right to request access to your information, request corrections, and request that your information not be used beyond the purposes stated above. To exercise these rights, contact us at studio@nickispice.com.
Studio Nicki Spice retains intake information for the duration of your client relationship and for a minimum of 3 years following your last visit, in accordance with applicable record-keeping standards.
I have read and understand the HIPAA Privacy Notice and consent to the collection and use of my health information as described above. *
Consent for Trichology Consultation and Treatment
By submitting this intake form, I consent to a trichology consultation and any agreed-upon scalp or hair treatments performed by licensed practitioners at Studio Nicki Spice. I understand that all services are non-medical and do not constitute a medical diagnosis or replace the care of a licensed physician.
I understand that my practitioner may recommend referral to a dermatologist, physician, or other healthcare provider when clinically appropriate. I acknowledge that results from trichology treatments vary by individual and are not guaranteed.
I confirm that the information provided in this intake is accurate and complete to the best of my knowledge. I agree to inform my practitioner of any changes to my health, medications, or conditions prior to future visits.
I consent to a trichology consultation and treatment at Studio Nicki Spice, and I confirm that the information provided in this intake is accurate and complete. *
This intake form is confidential and reviewed only by your assigned practitioner. Submitting this form is not a booking. Your practitioner will follow up within 48 hours to schedule your consultation. Studio Nicki Spice practitioners do not diagnose medical conditions. All clinical assessments are conducted in accordance with trichology best practices and applicable professional standards.