Your IP is: 38.107.179.210

First Name:

Last Name:

House Name/Number:

Street:

Town:

City:

State:

ZIP/Post Code:

Country:

Mobile/Cell Phone:

Telephone:

Email:

Sex:

Please Select Female Male

Best Contact Time:

What percentage of hair loss do you have?

Please select one Less than 25% 25-50% 50-75% 75-100%

How long have you been losing your hair?

Using diagrams below - Which type of hair loss pattern do you have?

Please select one Female - Grade 1 Female - Grade 2 Female - Grade 3 Male - I Male - II Male - II A Male - III Male - III Vertex Male - III A Male - IV Male - V Male - IV A Male - VI Male - VII Male - VA

Male Pattern Baldness

Female Pattern Baldness

Have you done anything about your hair loss?

Transplants Wigs Hairpiece Hair Extensions Other:

What made you decide to do something about your hair loss?

Look older than your age Medical hair loss Pressure from others Embarrassment Lack of confidence Socially unacceptable Depression Unattractive Less feminine Less masculine Other

What made you decide to do something about your hair loss?

Mousey Diffused Dry Textured Broken Fine Oily Thin Other

What color is your hair?

Please select one Black Dark Brown Brown Ash Brown Ash Blonde Blonde Grey Red Other

If you are interested in hair extensions then what are they for?

Fashion Length Thin Hair Highlights Fullness Volume Other

What situation bothers you most about your hair loss?

Please select one Wind Rain Swimming Meeting People Nights Out Work The Look Other Other

Do you use or perform cover-up?

Mane Spray Caps Blow Dry Hair Hats Hair Spray Thickener Scarfs Other

Do you, or have you used lotions/tablets for hair loss?

Rogaine Hormone Replacement Regaine Herbal Propecia Vitamins

Are you noticing more hair than usual in the shower drain, on your pillow, or in your hair bush?

Yes No

Have your immediate family members experienced hair thinning/hair loss?

Father Mother Sister Brother

What shampoo(s) do you use?

What conditioner(s) do you use?

What procedure(s) are you interested in?

Hair Graph Hair Integration Hair Extensions Hair Restoration - Medical Hair Servicing Other

What are your hobbies?

What is your occupation?

How did you hear about us?

What other hair loss companies are you familiar with?

Any other information you would like an Elitist to know?