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Consultation Form
Strictly Private and Confidential - City Gate
Full Name 姓名
*
Date of Birth 出身日期
*
Contact Number 电话
*
Email Address 地址
Gender 性别
*
Gender 性别
A
Female 女
B
Male 男
How do you know us 如何认识我们?
Your Desired Hair & Scalp Results 你想要看到的头皮头发效果
Desired Results 结果:
*
Desired Results 结果
Increase Hair Growth 促进头发生长
Reduce Hair Loss 减少掉发
Remove Dandruff 去除头皮屑
Lesser Grey Hair 减少白发
PH Rebalancing 平衡PH值
Anti-Ageing 抗衰老
Reduce Itchy Scalp 减少头皮发痒
Other 其他
Lifestyle 生活方式
Stress Level 压力水平
Stress Level 压力水平
1
2
3
4
5
Scale 1 = No Stress 没压力
Occupation 职业
Occupation 职业
Management / Accountant 管理 / 会计
Admin 行政
Outdoor 户外
Shift 轮班
Other 其他
What are your sleeping hours 睡眠时间?
What are your sleeping hours 睡眠时间?
A
12 hours 小时
B
10 hours 小时
C
8 hours 小时
D
6 hours or lesser 小时或更少
How often do you exercise 您有经常做运动吗?
How often do you exercise 您有经常做运动吗?
A
Regularly 经常
B
Occasionally 偶尔
C
Rarely 很少
Do you take any supplements, slim pill or protein shake 您有服用任何补助品, 减肥药, 蛋白饮品?
Do you take any supplements, slim pill or protein shake 您有服用任何补助品, 减肥药, 蛋白饮品?
A
No 不
B
Yes 是的
How often do you shampoo 您多久洗一次头发?
How often do you shampoo 您多久洗一次头发?
A
Everyday 每天
B
Alternate Days 隔天
C
Other 其他
How many strands of hair do you lose a day 一天所脱落的发量? (Shampooing 洗发 and on pillow 枕头)
How many strands of hair do you lose a day 一天所脱落的发量? (Shampooing 洗发 and on pillow 枕头)
A
Not sure 不确定
B
Estimate 估计的
Type of Shampoo 洗发水的类型
How often do you do chemical treatment 您经常染烫头发吗? Once every _ month 个月一次
Have you done any hair or scalp treatments 您有做过头皮头发护理吗?
*
Have you done any hair or scalp treatments 您有做过头皮头发护理吗?
A
No 不
B
Yes 是的
Medical History 病史
Any medical illness 您有任何疾病吗?
*
Any medical illness 您有任何疾病吗?
A
No 不
B
Yes 是的
Are you under medication 服用任何医药?
*
Are you under medication 服用任何医药?
A
No 不
B
Yes 是的
Do you have any allergy 您有任何敏感吗?
*
Do you have any allergy 您有任何敏感吗?
A
No 不
B
Yes 是的
Youngest child age 最小的孩子年龄
Acknowledgment
I am 21 years old and above 我已超过 21 岁
*
I am 21 years old and above 我已超过 21 岁
A
Yes
B
No
Customer Data Acknowledged
I hereby certify the above information provided by me is true to the best of my knowledge, which is sufficient for the consultation to be accurate. 我证明以上提供的个人资料实属真实，这份资料使用在咨询服务是准确无误的。
*
PDPA Acknowledged
I agree that my personal information collected, photos and videos taken of me may be stored and used in accordance with Bio Organicare's Privacy Policy comply with the Personal Data Protection Act 2012 (“PDPA”). 我同意我在这收集的个人资料、照片和视频可以根据 Bio Organicare 的隐私政策进行存储和使用，符合 2012 年个人数据保护法。
*
CCTV Acknowledged
I acknowledge and accept that Bio Organicare is secured with CCTV on their property and the main function is focused on staff and customer safety and protection. 我接受 Bio Organicare 在他们的地方中受到闭路电视的保护，主要目的是关注员工和客户的安全。
*
Customer Signature 客户签名
Customer Signature 客户签名
*
Submit
