top of page
successful-caucasian-young-woman-in-swimsuit-and-w-2023-12-05-22-25-25-utc-2.jpg

Service Consent

Please complete this consent form for your service.

What Brings You In Today?

How often do you get the following services?

Are you presently taking any medications or are you under a physician's care?
Yes
No
Are you planning on having surgery in the next 6 months?
Yes
No

Migraine headaches, history of scalp problems, etc. Please explain

MEDICAL INTERACTIONS THAT MAY CAUSE HAIR LOSS

Some drugs have been reported as causing hair loss in some individuals. While not everyone will experience hair loss, some drugs are more likely to cause hair loss than others.


The following is a partial list of drugs that have been reported to have a side effect of hair loss:

  • Cholesterol-lowing drugs Clofibrate (Atromin-S) Gemfibrozil (Lopid)

  • Parkinson's medications Levodopa (Dopar, Larodopa)

  • Ulcer drugs Cimetidine (Tagamet), Ranitidine (Zantac), Famotidine (Pepcid)

  • Anti-coagulents Coumarin, Heparin

  • Agents for Gout Allopurinol (loporin, Zyplotrim)

  • Anti-arthritics Penicillamine, Auranofin (Ridaura) Indomethacin (i/Indicin) Naproxen (Naprosyn) Sulindac (Clinorilo), Methotrexate (Folexo)

  • Anti-convulsants Trimethadion (Tridione)

  • Beta Blockers Atenolol (Tenormin), Metoprolol (Lopressor) Nadolol (Corgard), Propranolol (Inderal), Timolol (Blocadren)

  • Anti-Thyroid agents Carbimazole, lodine, Thiocyanate, Thiouracil

  • Calcium Channel Blockers Calan 240mg.

  • Others Blood thinners, Some male hormones (Anabolic steroids), Most anti-cancer medications, Drugs derived from vitamin-A Isotretinoin (Accutane), Etretinate (Tegison), Anti-depressants, Tricyclics, Amphetamine


The above drugs are only a few of the drugs that have been reported as contributing toward hair loss. If you suspect your hair loss is due to medication, consult with your doctor and pharmacist.


Photography Release Form


I give my permission to KT Hair Co., LLC to show or use all before and after pictures in public. I will not recieve any gratuity or fee.


I have read, intialed and understand my Home Care Maintenacnce sheet. If I do not follow the above instructions, I understand KT Hair Co Salon cannot be held responsible.

bottom of page