Hairline Clinic - Free Hairloss Evaluation :: hair loss calls for unique hair replacement solutions



	HairLine Company Home About Us Testimonials History Staff Media News Personal Solutions Surgical Methods Before / After Photos Dr Weiss Non-Surgical Chemo Wigs Folligraft Hollywood Laser Therapy Medical Propecia / Finasteride Rogaine / Minoxidil Hair Loss Women & Hair Loss Cause Of Hair Loss What Works What To Avoid Education More Information Receive a Free DVD Contact Information Contact Us Free Hair Loss Evaluation Sign Up for our Newsletter Internet Resources Links



	Contact Information 1 800 322 1237 Akron Consultation Office phone: 330 633 5225 1525 Home Ave. Akron, Ohio 44310 view mapquest map Cleveland Consultation Office phone: 216 573 5900 6505 Rockside Rd. #475 Independence, Ohio 44131 view mapquest map

Contact us today! 1 800 322 1237

Free Hair Loss Evaluation

Please fill out the following form, and hit send so we may provide you with your free, confidential hair loss evaluation by a member of our professional staff.

Please tell us about yourself:
* Indicates a Required Field

*First Name:
*Last Name:
Year of Birth:

Address:
City:
State:	Zip:

*EMail:

Primary Phone:
Evening Phone:

Best time to contact you:

Please tell us about the kind of hair loss you are experiencing:

1. How long have you been losing your hair ?

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

2. Where has the hair loss occured ?

( A ) ( B ) ( C ) ( D ) ( E )

3. Is the scalp visible in the area where you have lost your hair ?

Yes.

No.

4. Do you suffer from... ? ( choose as many as applicable )

Dandruff.	Dry Scalp.
Itchy Scalp.	Oily Scalp.

5. Would you characterize your exsisting hair as... ( choose one )

Dry.

Oily.

Normal.

6. Is the hair growing on the sides of your head ? ( choose one )

Thin and full.

Thick and full.

Thin and slightly receding.

7. Does your scalp ever flake ?

Yes.

No.

8. Do you ever see red blotches on your scalp ?

Yes.

No.

9. How would you rate your current hair loss ? ( choose one )

Light.

Moderate.

Heavy.

10. Have you experienced an increase in your rate of hair loss in the past years ?

Yes.

No.

11. Have you ever tried to do something about your hair loss ?

Rogaine.	Lotions / Shampoos.
Hair Transplant.	Nothing.
Hair Replacement.

12. Have you ever seen a doctor about your hair loss ?

Yes.

No.

13. Has anyone ever mentioned your hairloss to you ?

Wife.	Girlfriend.
Husband.	Boyfriend.
Mother.	Father.
Other.

14. Does that bother you ?

Yes.

No.

15. Why do you want to do something about your hair ?

I look older than I feel.

I hate the way my hair looks.

I want to meet younger men / women.

People make fun of me.

16. Do you want to:

Stop your hair loss.

Have more hair.