Free Confidential Hair Loss Online Consultation Form

Please complete this form as accurately as possible and one of our specialists will contact you to complete your evaluation. As with all of our services, this form is held with the most strict confidence and will not be made available to any other parties. Please be sure to include either your mailing address or your phone number if you wish to be contacted.

Name:
Address:
City, State & Postal ZIP:
E-Mail Address:
Phone:
Date of Birth:	January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
1. How long have you been losing your hair?
1-3 years 3-7 years 7-15 years more than 15 years
2. Which picture best discribes your hair loss situation?
Choice 1 Choice 2 Choice 3 Choice 4 Choice 5 Choice 6 Choice 7 Choice 8
3. Is the scalp visible in the area where you have lost your hair?
Yes No
4. Do you suffer from...? (Select as many as applicable)
Dandruff Itchy Scalp Dry Scalp Oily Scalp
5. Would you characterize your existing hair as...(Choose one only)
Dry Oily Normal
6. Is the hair growing on the sides of your head? (Choose one only)
Thin and full Thick and full Thin and slightly receding
7. Does your scalp excrete excessive sebum (oils)?
Yes No
8. Have you ever experienced a build-up of sebum (oil) on your scalp?
Yes No
9. Does your scalp ever flake?
Yes No
10. Do you ever see red blotches on your scalp?
Yes No
11. How would you rate your current rate of hair loss? (choose one only)
Light Moderate Heavy
12. Have you experienced an increase in your rate of hairloss in the past year?
Yes No
13. Have you ever tried to do anything about your hairloss?
Rogaine Hair Transplant Hair Replacement Lotions/Shampoo Nothing
14. Have you ever seen a doctor about your hairloss?
Yes No
15. Has anyone ever mentioned your hairloss to you?
Wife Girlfriend Husband Boyfriend Mother Father Other No
16. Does that bother you?
Yes No
17. Why do you want to do anything about your hair?
I look older than I feel I hate the way my hair looks I want to meet younger men/women People make fun of me
18. Do you want to:
Stop the hairloss? Have more hair?

When you are ready to submit the above information, just click on the button below.