Full Name
*
Email
*
Phone
*
1 of 5
What made you first notice your hair loss?
*
Negative comments from family, friends or others
I saw a picture of myslef
I've been seeing excessive hair loss on my pillow or when taking a shower
Other
What bothers you most about losing your hair?
*
Balding makes me feel older
I feel insecure
Balding makes me feel less attractive
other
2 of 5
What concerns you most about getting a hair transplant?
*
Pain
Cost
Scarring
Other
3 of 5
Have you considered any of the following options (below)?
*
Rogaine
Propecia
Wigs
PRP
None of the above
Have you ever considered shaving yourself bald as an option?
*
Yes
No
4 of 5
What would be the best thing about having your hair back?
*
I would feel younger
I would feel more secure
I would be more attractive
Other
Do you know the difference between FUT and FUE hair transplant procedures?
*
Yes
No
I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.
5 of 5
