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Free Hair Loss Evaluation

Please fill out the following form, and hit send so we may provide you with your free, confidential hair loss evaluation by a member of our professional staff.

Please tell us about yourself:

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First Name:	*
Last Name:	*
Year of Birth:
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Primary Phone:
Evening Phone:
Email:	*
Best time to contact you:

1.	How long have you been losing your hair?*
	1 - 3 years 3 - 7 years	7 - 15 years More than 15 years
2.	Where has the hair loss occurred?*

	(A) (B) (C)	(D) (E)
3.	Is the scalp visible in the area where you have lost your hair?*
	Yes.	No.
4.	Do you suffer from...? (choose as many as applicable)*
	Dandruff. Itchy scalp.
	Dry scalp. Oily scalp.
5.	Would you characterize your existing hair as... (choose one)*
	Dry. Oily. Normal.
6.	Is the hair growing on the sides of your head? (choose one)*
	Thin and full. Thick and full.	Thin and slightly receding.
7.	Does your scalp ever flake?*
	Yes.	No.
8.	Do you ever see red blotches on your scalp?*
	Yes.	No.
9.	How would you rate your current hair loss?*
	Light. Moderate.	Heavy.
10.	Have you experienced an increase in your rate of hair loss in the past 10 years?*
	Yes.	No.
11.	Have you ever tried to do something about your hair loss?*
	Rogaine. Hair Replacement Hair Transplant	Lotions/Shampoos Nothing
12.	Have you ever seen a doctor about your hair loss?*
	Yes.	No.
13.	Has anyone ever mentioned your hair loss to you?*
	Wife Husband Mother Other	Girlfriend Boyfriend Father
14.	Does that bother you?*
	Yes.	No.
15.	Why do you want to do something 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.
16.	Do you want to:*
	Stop your hair loss	Have more hair

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