*Please complete this form in its entirety; fill in every field in order
to submit. Fields that do not apply to you should be filled in with "N/A"
only. Thank you for your attention!
Do you need someone other than yourself to make a financial decision to
begin your TricHolistic Program? (If so, we ask they be present during
How do you relieve stress? (Check all that apply)
Scalp Condition: (Check all that apply)
Hair Condition: (Check all that apply)
Hair dryer temperature: (Check all that apply)
By submitting this TricHolistic Profile Web Form, I solemnly declare that
the information that I have given on this profile is correct in all respects.
I understand that supplying false information could hinder my treatment.