Zelda Hair Clinic
New Patient Intake Form
Complete your secure online intake form before your scheduled consultation.
Your responses help Dr. Zelda Harding prepare for your visit and better
understand your hair, scalp, nutrition, health, and wellness concerns.
Thank you for choosing Zelda Hair Clinic. Our comprehensive
patient intake form allows Dr. Zelda Harding, an experienced
Trichologist, Hair Loss Practitioner, and Functional Nutrition Consultant,
to review your health history, lifestyle, hair concerns, scalp condition,
nutrition, and wellness goals before your consultation.
This information helps us identify factors that may be contributing to hair
loss, scalp disorders, or other wellness concerns and supports the development
of recommendations tailored to your individual needs.
The form typically takes 20–30 minutes to complete. Please
answer each question as thoroughly and accurately as possible. Information
submitted through this form is used to prepare for your consultation and
support your care.
Before You Begin
Please have the following information available:
- Your current medications and nutritional supplements
- A list of known medical conditions or allergies
- Recent laboratory results, if available
- Your current hair-care products and treatments
- Clear photos of your hair and scalp, if available
Your personal and health information is used to prepare for your consultation
and provide personalized care.
When you are ready, complete the Patient Intake Form below.