To book your free, confidential appointment, please
fill out the following form.

First Name

Last Name

Address

City

State

Zip

Primary Phone

Evening Phone

Year of Birth

Best time to call you

What is your current monthly budget
for hair maintenance

How long have you been losing your hair?

1-3 year
3-7 years
7-15 years
More than 15 years

Where has the hair loss occured?

Top front
Top middle
Back center
Sides

Do you suffer from...?

Dandruff
Itchy scalp
Dry scalp
Oily scalp

Would you characterize your existing
hair as...

Dry
Oily
Normal

Is the hair growing on the sides of
your head...

Thin and full
Thick and full
Thin and slightly receding

Does your scalp ever flake?

Yes
No

How would your rate your current rate
of hair loss?

Light
Moderate
Heavy

Have you experienced an increase in your
rate of hair loss?

Yes
No

Have you ever tried to do anything about
your hair loss?

Yes
No

Have you seen a doctor about your
hair loss?

Yes
No

Has anyone ever mentioned your
hair loss to you

Wife
Girlfriend
Husband
Boyfriend
Mother
Father
Other

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
I feel insecure about my hair

Do you want to...

Stop your hair loss?
Have more hair?

How did you hear about us?

Radio show
Newspaper article
TV ad
Print ad
Radio ad
Family/friend
Intenet
Phone book
Hair stylist
Magazine

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© 2007 Hair Professionals All Rights Reserved. Site Design by ADP Studios .

Home | About Our Staff | Procedures | Client Photos | Testimonials | Frequently Asked Questions | Hair Replacement Guide | Videos | Contact Us © 2007 Hair Professionals All Rights Reserved. Site Design by ADP Studios.