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Due to the high volume of questions we receive,
please allow 15 days for a proper response.


Mrs Miss Mr
   
Last Name *
First Name *
Address*
Postal Code*
City*
Country*
Tel. * (ex. 0123456789)
E-mail*
Birthdate*
Are you already a customer somewhere else?
If yes, where?
* required information

PROFILE HAIR
SHAMPOOING FREQUENCY:  
TYPE :
HAIR : Natural Colored
Permed Weave
SCALP :  
DANDRUFF : Itching
ASPECTS : LENGTH :
ENDS : Dry Split  
HAIR LOSS:    
If yes, since when?  
THINNING HAIR
In which area?  
HEREDITY: If yes ?
DIET: If yes, how many kilos have you lost?
CHILDBIRTH: If yes, when?
GENERAL ANESTHESIA: If yes, when?
     
SOMETHING YOU’RE CONCERNED ABOUT,
WE WILL RESPOND TO YOU WITH OUR BEST ADVICE:

For a more personalized response, please complete this questionnaire as accurately as possible.
For a more personalized response, please complete this questionnaire as accurately as possible.
 
 
Institut Technique de Recherches Capillaires
8, rue Papon - 06300 NICE
Tel. : +33 4 93 80 55 80
Fax : +33 4 93 62 62 61
info@cliniqueducheveu.fr

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