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Free Hair Evaluation
Submit the answers to the following questions and we will contact you with the best solution for your hair condition.
Current Age:
Age you started losing your hair:
How much hair do you lose daily? (choose one)
20 hairs
20-50 hairs
over 50 hairs
Indicate your current state of baldness by checking the one illustration below that most resembles your hair loss condition. (Women may skip this question)
A
B
C
D
E
Regarding the illustration you checked above, how long have you looked like this?
(number of years)
What is the texture of your hair?
Thick, curly
Thick, straight
Thin, curly
Thin, straight
Do you suffer from any allergies?
Are you currently taking any kind of medication? If so, please list them
Has anyone in your family experienced hair loss? (check all that apply)
Mother
Father
Aunt
Uncle
Sibling(s)
Has the average number of hair you lose per day increased in the past three years?
First Name *required
Yes
Last Name *required
No
Phone *required
Email *required
Address *required
City *required
State *required
Zip *required
Additional Comments?