HAIR LOSS EVALUATION FORM

 
If you are considering surgical hair restoration, complete the Hairloss Evaluation below to receive a personal treatment plan with recommendations that best suit your hair loss condition. Our consultant will respond via email or telephone. We assure you that the information you send will be kept confidential.

Please keep in mind, your online or telephone evaluation will help you learn about viable solutions to your hairloss condition; however, it will not replace a one-on-one evaluation.
 

Hair Loss Eval
Which characteristic best describes your natural hair?
Straight Wavy Curly
What is the texture of your hair?
Fine Medium Thick
Click on the image that best depicts your hairloss condition when your hair is wet.
Is your hairline receding at the temples?
Yes No
Are you experiencing hairloss on the top/front of your head?
Yes No
Treatment History
Have you ever had surgical hair restoration performed?
Yes No
When would you like to have a procedure performed?
Optional, but extremely helpful. Take four close-up photos to illustrate your baldness pattern (see examples to the right for correct camera angles).

Send us your photos via email or courier.
Personal Profile
First Name:
Last Name:
Date of Birth :      
Gender:
Address:
City:
State:
Country:
Phone Number:
Mobile/Cell Number:
Email Address:
Contact me by:
Phone Cell Email Any
Please Email me notices of new developments and special offers as they become available.
How were you referred to our practice?
Do you have any question or comment?

 
 
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