Ready to take control of your hair loss? Get Answers Now!

You’re about to take the first step to restoring your hair! By taking this quick test, you’re headed in the right direction to feeling your best about your hair once again. Get started by answering the following questions. Once you submit your responses, one of our Elite Hair Loss Specialists will contact you as soon as possible.

 


 

About Your Hair Loss

Please describe your current degree of hair loss.
Please answer.
Please answer how long you have been experiencing hair loss.
Please select which of the following you are currently experiencing.
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Please answer if any of your relatives have hair loss or thinning hair.
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Please answer if you are currently taking prescription medication.
Please explain.
Please answer if you have tried or considered hair loss replacement options.
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Please answer which part of your scalp is most concerning to you.
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Please enter how hair loss has affected your life.

About You

Please select if you live near Sacramento, California.
Please select the term that best describes your gender identity. You can enter a custom term if preferred.
Please explain your gender.

Contact Information

Please enter your first name.
Please enter your last name.
Please enter your email address.
Please enter a valid phone number (123-456-7890).
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