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Hair Loss Questionnaire

This questionnaire has been put together to serve you and to ensure that you will understand the hair replacement procedure and to inform you of other hair replacement methods that are available today. You are under no obligation to have any work performed. Our staff is here to answer all of your questions and allow you to make your own informed decision.

Name: Address:
City: State:
Zip: Country:
Phone: E-Mail:
Age: Gender:

Please check those that apply:

I would like a more permanent application than a daily on/off hair piece:

I would like a non-medical application w/ the ability to service myself:

I would like my hairline lowered:

I would like to fill in my hairline:

I would like to add thickness to my remaining hair:

I would like to add fullness to my existing hair transplants:

I would like to have my total balding area replaced:

I only need hair in the crown area:

I would like a full head of hair:

I would like a light density of hair:

Please check the box that most resembles your current state of hairloss:

Comments/Questions:

 
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