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Client Pre-Authorization Questionaire

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Thank you for visiting us. By filling out this 5-10 minute survey, you will help us obtain the very best results.

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1

Are you over 18ys old?

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2

Are you pregnant or nursing?

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3

Are you experiencing open or draining wounds/lesions on the scalp?

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4

Do you currently have severly inflamed scalp - a severe sunbrun, bacterial infection, fungal infection etc.?

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5

Are you a breast cancer survivor?

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6

Have you had cardiac arrest (heart attack)?

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7

If you have had cardiac arrest, do you agree to checking with your physician before using Minoxidil?

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8

Do you have metal plates in your head or history of brain tumors or melanoma?

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9

If you have metal plates in your head or history of brain tumors or melanoma, do you agree to checking with your physician before treatment?

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10

Have you had scaring alopecia before?

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11

If you have had scaring alopecia before, do you understand that you are only going to strengthen your existing hair. Do you understand that once the follicle is destroyed there is no way to grow hair back in that area?

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