DATE E-MAIL

FIRST NAME LAST NAME

MEDICAL CONDITIONS: _______________________________________

________________________________________________

SCALP CONDITIONS:

www.cqtinternational.com NORMAL ___ OILY ___ DRY ___ FLAKEY SKIN ___ HYPERHIDROSIS ___

HAIR CONDITION
O2 THERAPY TREATMENT

THICK ___ MEDIUM ___ FINE ___ SPLIT ENDS ___

CHEMICALLY TREATED ___ SENSITIVE ___ BREAKAGE ___

METHIOPEPTIDER®

PARTICULARITIES:

_________________________________________

_________________________________________

_________________________________________

OBSERVATIONS AFTER TREATMENT IN SALON:

_______________________________________________

________________________________________________

________________________________________________

DIRECTIONS FOR HOME CARE APPLICATION:

_________________________________________________

_________________________________________________

________________________________________________
 DATE E-MAIL

FIRST NAME LAST NAME

SUGGESTED TREATMENT:

WEEK 1 ______________________________________________

WEEK 2 ______________________________________________

WEEK 3 ______________________________________________
www.cqtinternational.com
WEEK 4 _____________________________________________

MONTH 2 ____________________________________________
O2 THERAPY TREATMENT

____________________________________________________

MONTH6 ____________________________________________

____________________________________________________

1 YEAR ______________________________________________

____________________________________________________
METHIOPEPTIDER®

HOME CARE TREATMENT:

WEEK 1 __________________________________________

WEEK 2 __________________________________________

WEEK 3 __________________________________________

WEEK 4 __________________________________________

MONTH 2 ______________________________________________

______________________________________________________

MONTH 6 ______________________________________________

______________________________________________________

1 YEAR ________________________________________________

______________________________________________________